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Dislocated and Fractured 5th Metacarpal? Surgery?

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(I should say I am in South Korea and being treated by Korean speaking M.D.s... I don't speak Korean.)

Exactly two weeks ago I punched a wall and gravely injured my right and dominant hand. It was obviously very swollen the next day and as the week progressed, was very painful. My palm bruised the size of a large orange and a raised angle (low grade bump?) appeared on the top right edge of my hand above the 5th metacarpal, closer to the wrist than the knuckle.

Having just recovered from surgery on my head, I had my dermatologist look at it the first week. He had me flex my hand, which though slightly painful, I seemed to be able to do at 100%. He said it was "good" and not to worry.

Fearing missed time at work and the bills, I decided to forgo a visit to an orthopedic surgeon... until today. After X-Rays, I was told that I fractured my 5th metacarpal and because I had waited two weeks, it was dislocated. The doctor said I needed surgery and, if not I would lose my grip and have a deformed hand.

They set me up with an orthopedic surgeon on Monday, but I have to bring an interpreter. (Impossible for me.) I am just hoping to find out if this surgery is something I can forgo. My hand is working, but certain angles of my wrist are excruciatingly painful. I can write and carry a coffee cup (thank God Wink, but there is still a lot of pain after two weeks.

My Grip seems find, and aside from the pain now and the bump on hand, everything looks ok.

Any advice would be more than appreciated.

I have the X-Rays handy.
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First Helper User Profile Gaelic
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replied December 21st, 2012
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givemeahand,

Sorry about your injury.

Unfortunately, not all fifth metacarpal fractures are the same, and as such they are all treated differently. Without knowing exactly where your metacarpal is fractured, it is not really possible to tell you if surgery will be necessary.

You have also found out that the old, "can you move the hand/fingers, good it is not broken" is not true. Many patients have pretty good motion, yet still have broken bones.


You also stated, "I was told that I fractured my 5th metacarpal and because I had waited two weeks, it was dislocated." I believe what you mean is that the fracture was displaced, rather than dislocated. I know it is picky in terms of wording, but displaced and dislocated mean very different things to an orthopedic surgeon. A displaced fracture means that the bone is no longer in anatomical alignment. A dislocation refers to a joint, in which the bones of the joint are now not making up the joint correctly (such as a dislocated shoulder).

There is a fracture/dislocation of the fifth metacarpal, where the base of the fifth fractures and then also dislocates from its articulation with the hamate (the carpal bone that the fifth articulates with). Unfortunately, if the fifth remains dislocated, it is usually recommended that this be surgically treated, to get the joint back into its proper alignment. Most of the time, the fragments of the base are pinned together with c-wires, then the metacarpal is reduced to the hamate, and it is pinned into position. If it is left dislocated, it usually results in pretty significant traumatic arthritis.


Shaft fractures of the fifth metacarpal can be treated with casting, if there is not significant angulation or displacement. Sometimes the angulation can be corrected with a closed reduction and then it can be held with a well molded short arm cast. The small and ring fingers are usually buddy taped, to prevent rotational deformity from occurring.

If the metacarpal shaft fragments are displaced, it is usually recommended that they be reduced surgically, because most of the time, when the fragments displace some of the soft tissue (mainly the intrinsic muscles of the hand) becomes interposed between the fragments. If there is soft tissue interposition, the bone cannot unite (heal).

If the fragments are rotated, surgery is usually recommended. Rotation is one deformity that the body cannot remodel or compensate for.

So, again, some shaft fractures can be treated with closed reduction and casting. The others, they are usually treated with open reduction and internal fixation (ORIF), using a “small frag” plating system.


Fractures of the fifth metacarpal which are located at the neck of the metacarpal are called the classic “boxer’s fracture”. Many of these fractures, even though they have significant angulation, can be treated with immobilization. While it is usually recommended that the angulation be reduced to thirty degrees or less, there have been studies done which show that patients can function quite well with angulations of up to seventy degrees. The patient will not have a knuckle at the base of the small finger (which occurs in almost all boxer’s fractures, known as a “knock down hand”) and may have a prominence in the palm of the hand, at the base of the small finger.

As long as the distal fragment does not rotate or the fracture lines do not go into the head (and into the joint), most boxer’s fractures can be treated with immobilization.



So, again, without knowing what your fracture actually is, it is not really possible to give you exact information.


Hope you do well with your upcoming appointment. Good luck.
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replied December 24th, 2012
Gaelic, thanks a lot for the thoughtful response! I made an appointment to see an orthopedic surgeon in a couple weeks. It's been 2.5 weeks since the injury and it's still slightly swollen and quite painful.

The first doctor I saw did say that it was dislocated and fractured, but I see your point and wonder if there was just the language barrier. Maybe he meant to say it was displaced. I do not know the degree of angulation. I wish I did.

I am concerned about surgery, as I am leaving Korea in 2.5 months. Can you tell me about how long on average these types of surgical procedures take to heal? I've heard that there is usually some physical therapy to be done for awhile after healing, but is two months enough time to have surgery and appropriate aftercare?

Also, here are links to a couple x-rays. Thanks again for taking the time to answer my questions! Merry Christmas!


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replied December 24th, 2012
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givemeahand,

Unfortunately, you have a base of the fifth metacarpal fracture. I would need to see the true lateral to see if the shaft is dislocated significantly.

From the PA and oblique it appears that you have a comminuted fracture (broken into more than just two pieces). There is one piece, which is the radial condyle of the base, which is still attached to the base of the fourth metacarpal base by the proximal intermetacarpal ligament.

It is difficult to tell if the piece which is makes up the articular surface is just one big piece (which would be good), or if it is also broken into several pieces.

The shaft also has a fracture line going up the shaft to about a third of the way (you can see this best on the oblique film).

You can tell that the metacarpal has shortened some. The shaft has moved proximally, down in between the other fragments. It is held from moving too much proximally, by the distal intermetacarpal ligament, which goes between the heads of the metacarpals.

Unfortunately, the tendon of the ECU (extensor carpi ulnaris) muscle attaches to the base of the fifth metacarpal. As such, it tends to pull the shaft fragment proximally and dorsally (back of the hand). It is the dislocating force in this injury.


If this fracture was presented to our clinic, we would normally get a CT scan (not an MRI) to determine if the base fragment was one big piece or if it the articular surface was significantly disrupted (broken into several small pieces).


We usually recommend that these fractures be treated surgically. If the fracture is fresh and the base fragment is one piece, usually the shaft can be pulled back out to length, reduced to the base fragment, and then pinned. Usually, one or two pins are placed transversely, going into the base of the fourth metacarpal, to hold the shaft out to length. Then, the shaft and base fragment are pinned to the hamate, to make sure the joint is reduced. We usually place the patient in a bulky compressive dressing to help with the swelling for the first 7-10 days. We then change the surgical dressing and place the patient is a well padded cast (in James position) for another three or four weeks. At that time, if the x-rays show good callus formation, the pins are removed in the clinic and the patient is placed into a well molded short arm cast for another two weeks (with the small and ring fingers buddy taped). The patient can begin working on finger motion. At around six weeks post-op, the immobilization is discontinued and the patient is allowed to start therapy for wrist motion. We sometimes use a removable wrist splint for patient comfort, while the patient is regaining wrist motion and strength.


If the base fragment is broken into several small pieces, then frequently the fracture has to be opened so that the articular surface (joint surface) can be put back together as smoothly as possible. The fragments are again pinned together, and then to the fourth metacarpal base and hamate. The post-op treatment is the same.


You also have the fracture that goes up the shaft. At present, it is not displaced. But, it may also have to be addressed, because it could get displaced with the base is manipulated. So, it may be that the fracture would have to be opened, the shaft plated with a “mini frag” plate, then the base could be pinned.

Anyway you look at it, it is going to be a difficult surgery. Also, since this is an intra-articular fracture (the fracture goes into the joint), the chances of developing traumatic arthritis in the joint is much higher down the road.



Also, you are now getting on to three weeks after your injury. It is not uncommon for hand fractures to heal within four to six weeks. Thus, you may already have a significant amount of healing going on around the fracture site, which makes the surgery that much more difficult. It most likely will not be possible to move the fragments around anymore by just pressing on them from the outside (closed reduction), so any surgery will most likely have to be done open.



There is also another possibility of how this type of fracture can be treated. In cases where the base of the fifth is just broken into many, many small fragments, where it is just not possible to get the pieces back together (a “Humpty-Dumpty” type of fracture), the shaft is pinned to the hamate (if needed to get the bones in a general alignment), and the fracture is just allowed to heal. There is not a lot of motion at the fifth metacarpal/hamate joint, so some patients do not have a lot of problems after this. The area fills in with fibrous tissue (a type of scar), and the joint sort of reconstitutes itself. However, if the patient does develop pain at the base of the fifth with activity, then there is a type of arthroplasty (joint reconstruction) which can be done (once the bone is fully healed).

In this arthroplasty, the base of the fifth is resected (taken out) and the hole that is left is filled in with a piece of rolled up tendon graft (called an “anchovy”). The capsule of the joint is closed over this “anchovy” to hold it in place, and the shaft of the fifth pinned, until the soft tissues have healed. This tendon graft anchovy transforms into sort of a rubbery bumper, so that there is no longer any bones grinding together.

There is also an experimental “total joint replacement” for the base of the fifth. Again, it is experimental and is only done in research centers. But, it may be out on the market in the near future.

The above options are only if the base is just not repairable.



Hope that was not too much information for you. South Korea actually has many very good hand surgeons. They publish often in the Journal of Hand Surgery and present at the ASSH (American Society for Surgery of the Hand) conventions. I actually trained under a gentleman from South Korea, who is now a very well known hand surgeon at West Virginia University, by the name of Jaiyoung Ryu. So, you should be able to find a hand surgeon to take very good care of you.


Hope that you get your hand taken care of soon. You do have a pretty significant injury (you did a number on yourself). Try to keep your hand elevated as much as possible (above your head). Some compression and ice will also help with the swelling. The more you can reduce the swelling, the easier the surgery will be.

Good luck.
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replied February 8th, 2014
ongoing pain on 5th metacarpal on left hand..pls help
hi great posts..im new to this but i do have massive pain on the lateral side of my left hand possibly from base of 5th metacarpal with shooting pain to mid arm coming and going...for 6months now but cannot recall punching or hitting or bumping into anything and im desperate for results my doctors just gave me dicloflenac and sent me on my way
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replied February 8th, 2014
hi great posts..im new to this but i do have massive pain on the lateral side of my left hand possibly from base of 5th metacarpal with shooting pain to mid arm coming and going...for 6months now but cannot recall punching or hitting or bumping into anything and im desperate for results my doctors just gave me dicloflenac and sent me on my way
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