Metacarpal Fx x2sm

Metacarpal fractures are commonly present to the Emergency Department for care. The plain film shown here shows metacarpal neck fractures of the middle and ring finger shown. There are specific criteria requiring closed reduction in the ED (PV Card). Generally ANY rotational angulation requires reduction. Detection of such angulation depends on the clinical exam rather than the plain film. How does one diagnose it?

Clinical exam to check for metacarpal fracture rotational angulation

You can check for rotational angulation using two approaches:

  1. With a closed fist, the fingers (excluding the thumb) should point to the scaphoid.
  2. When the fingers are loosely flexed, the fingernails should lie in a similar parallel plane. The fingers should not overlap, or “scissor”. 



This photo above demonstrates a third metacarpal neck fracture with rotational angulation requiring closed reduction in the ED. Because rotationally angulated metacarpal fractures require urgent reduction, be sure to document the absence of rotational angulation in your medical chart before discharging a patient home.



Mailhot T, Lyn ET.  “Hand” in Marx, Hockberger, Walls (eds), Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th ed. Mosby, Inc, 2013. 

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD