Handstand fracture

A handstand fracture is a specific metacarpal fracture category that affects the head of the metacarpal bone.

Clinical presentation

As the name implies, patients with such a fracture commonly present after losing balance from a handstand and sustaining a high-energy impact to the hand.

Patients may present with tenderness overlying the dorsal aspect of the hand, soft tissue swelling/oedema, visible physical deformity, and/or decreased grip strength ¹.

Pathology

Handstand fractures are considered intra-articular fractures as each metacarpal head articulates with its associated phalanx.

Mechanism

Metacarpal head fractures are a consequence of direct trauma or rotational injury with longitudinal axial loading to the metacarpal bone heads. Avulsion fractures secondary to collateral ligament rupture through torsional stress can occur in some cases ^2,3.

The second metacarpal head is most commonly involved in injuries due to its role as a lateral border for the hand ³.

Radiographic features

Metacarpal head fractures are almost always diagnosed through plain radiographs of the affected hand.

Plain radiograph

AP, lateral, and oblique radiographs of the hand are the three most commonly used views to diagnose a handstand fracture.

A Brewerton view (flexing the hand at the metacarpophalangeal joint to 65°) may be utilised if the fracture is subtle or not adequately visualised on the standard views ⁴.

CT

While not typically used in hand fractures, CT scans may be indicated in complex or comminuted metacarpal head fractures from traumatic crush injuries.

Radiology report

Important radiographic features that should be noted include, but are not limited to:

• number of metacarpals fractured

• comminution

• volar/dorsal angulation (assessed on lateral view)

• degree of displacement/rotation

• presence of intra-articular extension

• malalignment

• joint spaces

• soft tissue swelling

• other associated fractures or dislocations

Treatment and prognosis

Nonoperative management is indicated in stable, non-displaced fractures with no rotational deformity and minimal angulation. The metacarpophalangeal joints are immobilised in 70-90° of flexion with a thumb spica splint for ~4 weeks ^2,5.

Open reduction internal fixation with screws or K-wires is the treatment of choice in fractures with significant angulation or displacement ^5,6.

Rarely, external fixation is required in severely comminuted fractures.

Complications

In fractures with significant angulation and/or rotational deformity, malunion or non-union as a result of poor healing can occur ⁶.

Joint stiffness is a common complication of operative management, which can be prevented with early physiotherapy motion exercises.