An unusual split fracture of the fourth and fifth metacarpal heads in a young adolescent: a case report

Introduction and Importance: Metacarpal head fractures are rare intra-articular injuries categorized into 10 types by McElfresh and Dobyns. This report discusses the first reported case of simultaneous coronal head-split fractures of the fourth and fifth metacarpals, the unusual mechanism of injury, and our surgical management of this never-seen type of fracture. Case Presentation: We describe the case of a coronal head split fracture of the fourth and fifth metacarpals in an 18-year-old male who presented with severe pain in the knuckles following a punch. Radiographs of the left hand showed intra-articular fractures of the heads of his fourth and fifth metacarpals step-off of 3 mm. Fixation was performed using two crossed 1.2-mm headless compression screws, each inserted dorsal to palmar to restore articular surface integrity and congruency. A full active range of motion was achieved at 8 weeks postoperatively without rotational deformity. Clinical Discussion: We present our approach to patient management, comparing it to the existing literature. Given the articular step-off and the patient’s young age, open reduction and internal fixation with headless compression screws was performed. To the best of our knowledge, this is the first documented case of surgical management for this specific fracture pattern, highlighting our successful approach in achieving anatomical reduction and stable fixation, which facilitated early mobilization and a favorable outcome. Conclusion: This report highlights a viable surgical approach and major take-away points for this rare intra-articular injury, namely fracture pattern recognition, adherence to surgical principles, and achieving appropriate anatomical reduction and stable fixation to promote faster and successful recovery.