47-Year-Old With Right Hand Pain

Differential Diagnosis

• Hand sprain
• 4^th Metacarpal (barber pole) fracture
• 5^th Metacarpal (boxer’s) fracture
• Ulnar styloid avulsion fracture

Diagnosis

This is a 4^th metacarpal shaft fracture, specifically a “barber pole” fracture. Findings on the AP x-ray reveal a spiral band of sclerosis that has the appearance of a barber pole as well as a displaced spiral fracture of the 4th metacarpal on the oblique view. This type of barber pole fracture is common and may involve fractures of the metacarpal head, neck, and/or shaft. The mechanism of injury for a shaft fracture includes axial loading or direct trauma (eg, clenched fist and solid surface impact). Rotational and/or torsional force may also result in this type of injury.

What to Look For

• Metacarpal fractures are most often the result of direct trauma but may also occur from repetitive stress
• Locations metacarpal fractures include the head, neck, shaft and base of the metacarpal
• Key examination components include evaluation for bony deformity, malrotation, skin breakage and neurovascular compromise

Pearls for Urgent Care Management

• Metacarpal fractures with significant angulation first require reduction
• Treatment includes gutter splint immobilization for nondisplaced metacarpal fractures with minimal angulation and no malrotation; immobilize metacarpophalangeal joints in 70-90° of flexion and splint for at least 4 weeks
• Referral to orthopedics is indicated for open fractures, unacceptable angulation, malrotation, and multiple fractures for consideration of operative management

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