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7. Hand and Wrist MCQs

Practice Set 145 of 266

This practice set contains high-yield board review questions covering key concepts in 7. Hand and Wrist. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2881

Topic: 7. Hand and Wrist

A 45-year-old man presents with severe radiating right arm pain, weakness in wrist extension, and a diminished brachioradialis reflex. Sensation is decreased over the dorsal web space of the right hand. Which cervical nerve root is most likely affected?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C4

Explanation

A C6 radiculopathy typically presents with weakness in wrist extension and elbow flexion, a diminished brachioradialis reflex, and sensory deficits in the thumb and index finger (radial aspect of the forearm/hand).

Question 2882

Topic: 7. Hand and Wrist

A 72-year-old man with known cervical spondylosis falls forward and strikes his chin. He presents with severe motor weakness in his bilateral hands and arms (1/5 strength), but maintains functional strength in his legs (4/5 strength). Sensation in the perianal area is intact. What is the most likely diagnosis?

. Anterior cord syndrome
. Brown-Sequard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Anterior cord syndrome

Explanation

Central cord syndrome classically occurs following a hyperextension injury in patients with a pre-existing stenotic cervical canal. It presents with disproportionately greater motor weakness in the upper extremities compared to the lower extremities.

Question 2883

Topic: 7. Hand and Wrist

A 59-year-old man presents with deteriorating handwriting and difficulty buttoning his shirts. On examination, brisk tapping of the distal phalanx of the long finger elicits flexion of the thumb interphalangeal joint. What is this clinical sign, and what does it indicate?

. Wartenberg sign; ulnar neuropathy
. Hoffmann sign; upper motor neuron lesion
. Inverted radial reflex; C5 nerve root compression
. Babinski sign; lower motor neuron lesion
. Lhermitte sign; posterior column disease

Correct Answer & Explanation

. Wartenberg sign; ulnar neuropathy

Explanation

The Hoffmann sign is elicited by flicking the distal phalanx of the middle finger, causing reflex flexion of the thumb and index finger. It indicates an upper motor neuron lesion above the level of C5-C6, highly suggestive of cervical myelopathy.

Question 2884

Topic: 7. Hand and Wrist

A 70-year-old man with known cervical spondylosis falls forward and strikes his chin, hyperextending his neck. He presents with profound bilateral upper extremity weakness (especially in the hands) but is still able to ambulate with assistance. He has patchy sensory deficits. What is the most likely diagnosis?

. Anterior cord syndrome
. Brown-Sequard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Cruciate paralysis

Correct Answer & Explanation

. Anterior cord syndrome

Explanation

Central cord syndrome typically occurs after a hyperextension injury in patients with preexisting cervical spondylosis. It classically presents with disproportionately greater motor impairment in the upper extremities compared to the lower extremities, along with variable sensory loss.

Question 2885

Topic: 7. Hand and Wrist

A patient presents 4 weeks after sustaining a partial laceration to the flexor digitorum profundus (FDP) tendon in Zone II of the little finger. He has experienced some improvement in active flexion but still has a significant flexion lag at the distal interphalangeal (DIP) joint. Physical examination reveals a 45-degree lag at the DIP joint and intact passive range of motion. What is the MOST appropriate next step in management?

. Continue with hand therapy and passive range of motion exercises
. Begin aggressive active resistance exercises
. Perform a tenolysis
. Consider delayed primary repair or secondary reconstruction
. Immobilize the finger in a full flexion cast

Correct Answer & Explanation

. Continue with hand therapy and passive range of motion exercises

Explanation

A 45-degree flexion lag at the DIP joint 4 weeks post-partial FDP laceration in Zone II suggests a significant functional deficit and a high likelihood of chronic tendon adherence or an insufficient repair/healing. While hand therapy is crucial, such a substantial lag indicates a mechanical block that therapy alone is unlikely to overcome. Delayed primary repair can be considered up to 3 weeks, sometimes longer depending on the surgeon. At 4 weeks, with a significant lag, the tendon ends may have retracted or scarred, making a simple tenolysis insufficient if the tendon is still partially disrupted or significantly attenuated. A secondary reconstruction (e.g., tendon graft) may be required depending on the quality of the tendon and the gap. Aggressive resistance exercises would likely worsen the issue or cause complete rupture. Immobilization would lead to further stiffness and adhesion formation. Therefore, reassessment for possible surgical intervention (delayed repair if feasible, or secondary reconstruction) is warranted.

Question 2886

Topic: 7. Hand and Wrist

A 35-year-old male sustains a displaced intra-articular distal radius fracture (Frykman Type VIII) after a motorcycle accident. Examination reveals significant swelling and tenderness. Radial and ulnar pulses are intact, but he complains of numbness in the thumb, index, and middle fingers. Which of the following is the MOST urgent step in his management?

. Application of a sugar tong splint and follow-up in 1 week
. Emergency open reduction and internal fixation
. Closed reduction and assessment for carpal tunnel release
. Administration of intravenous corticosteroids to reduce swelling
. Immediate CT scan of the wrist

Correct Answer & Explanation

. Application of a sugar tong splint and follow-up in 1 week

Explanation

Numbness in the median nerve distribution (thumb, index, middle fingers) in the setting of a displaced distal radius fracture indicates acute carpal tunnel syndrome, which is a surgical emergency. The immediate concern is to relieve pressure on the median nerve. This often starts with an emergent closed reduction of the fracture and immobilization, which can decompress the nerve by reducing fracture fragments. However, if symptoms persist or worsen after reduction, or if there is profound and acute neurological deficit, an emergent carpal tunnel release may be necessary in addition to fracture stabilization (either closed or open reduction). Therefore, the MOST urgent step is to attempt closed reduction to decompress the nerve, then reassess. Emergency ORIF might be necessary for definitive fixation, but decompression of the nerve through reduction is paramount first. A CT scan can wait until the nerve decompression is addressed. Steroids are not a primary treatment for acute compressive neuropathy in this setting. A simple splint without addressing the median nerve symptoms is inadequate.

Question 2887

Topic: 7. Hand and Wrist

A 25-year-old male sustains a gunshot wound to the supraclavicular region, resulting in a flail arm. Clinical examination reveals complete loss of deltoid, biceps, triceps, wrist extensor, and intrinsic hand function. An MRI shows evidence of multiple root avulsions from C5-T1. What is the MOST appropriate surgical intervention?

. Neurolysis and direct repair of avulsed roots
. Exploration with nerve grafting of distal stumps
. Nerve transfers (e.g., intercostal to musculocutaneous, phrenic to suprascapular)
. Primary tendon transfers
. Observation and extensive physical therapy

Correct Answer & Explanation

. Neurolysis and direct repair of avulsed roots

Explanation

Root avulsions, as suggested by the MRI and flail arm presentation, indicate preganglionic injuries where the nerve roots are torn from the spinal cord. These injuries cannot be directly repaired or grafted at the root level because the nerve cells (motor neurons) are in the spinal cord and the roots are avulsed from them. The most appropriate surgical intervention for preganglionic injuries is nerve transfers, where a less critical nerve (donor) is coapted to a more critical, denervated nerve (recipient) distal to the injury site. Examples include transferring intercostal nerves to the musculocutaneous nerve to restore elbow flexion, or phrenic nerve to suprascapular nerve for shoulder function. Neurolysis and direct repair/grafting are reserved for postganglionic ruptures where the nerve is torn distal to the dorsal root ganglion. Tendon transfers are typically considered for reconstructive options after nerve recovery plateaus or for situations where nerve repair/transfer is not feasible or fails. Observation is not appropriate for a flail arm with avulsions.

Question 2888

Topic: 7. Hand and Wrist

A 55-year-old male presents with a progressive contracture of the ring finger and small finger in his right hand. He has a palpable cord in the palm extending into the fingers. The metacarpophalangeal (MCP) joint of the ring finger has a 40-degree contracture, and the proximal interphalangeal (PIP) joint has a 30-degree contracture. The small finger MCP is 50 degrees contracted, and PIP is 45 degrees contracted. Which surgical intervention is MOST appropriate for this patient?

. Percutaneous needle aponeurotomy (PNA)
. Collagenase injection (Xiaflex)
. Limited fasciectomy
. Dermofasciectomy
. Amputation of the affected fingers

Correct Answer & Explanation

. Percutaneous needle aponeurotomy (PNA)

Explanation

The patient presents with significant Dupuytren's contractures affecting both MCP and PIP joints of the ring and small fingers. The indications for intervention typically include an MCP joint contracture of 30 degrees or more, or any PIP joint contracture. Given the combined severity, surgical intervention is warranted. Percutaneous needle aponeurotomy (PNA) and collagenase injection (Xiaflex) are less invasive options, but they are generally most effective for isolated MCP joint contractures or less severe PIP joint contractures, and have higher recurrence rates. For significant PIP joint contractures, particularly those exceeding 20-30 degrees, limited fasciectomy (excision of the diseased fascia) is considered the gold standard and most effective treatment. Dermofasciectomy (excision of skin and fascia with skin grafting) is reserved for severe recurrent cases or very aggressive forms of the disease. Amputation is a salvage procedure for severe, irreversible contractures, usually with associated complications or non-functional digits, and not indicated here.

Question 2889

Topic: Nerve & Tendon

A 45-year-old machinist complains of progressive numbness and tingling in his ring and small fingers, worse with elbow flexion. He occasionally drops small tools due to hand weakness. Physical examination reveals tenderness over the cubital tunnel, a positive Tinel's sign, and atrophy of the first dorsal interosseous muscle. There is no Wartenberg's sign. Electromyography and nerve conduction studies confirm severe ulnar neuropathy at the elbow. What is the MOST appropriate next step in management?

. Elbow immobilization in extension
. Physical therapy with nerve gliding exercises
. Oral NSAIDs and Vitamin B6 supplements
. Cubital tunnel release
. Observation with activity modification

Correct Answer & Explanation

. Elbow immobilization in extension

Explanation

The patient's symptoms (numbness/tingling in ring/small fingers, weakness, first dorsal interosseous atrophy), signs (Tinel's at cubital tunnel), and confirmed severe ulnar neuropathy indicate significant ulnar nerve compression at the elbow (cubital tunnel syndrome). The presence of motor weakness and muscle atrophy signifies advanced neuropathy, for which conservative management (immobilization, physical therapy, NSAIDs, observation) is unlikely to be sufficient and may lead to irreversible motor loss. Surgical cubital tunnel release (either in situ decompression, anterior transposition, or medial epicondylectomy) is indicated for severe or progressive cases, especially with motor deficits. Early surgical intervention in severe cases is associated with better outcomes and less risk of permanent neurologic deficit. The absence of Wartenberg's sign suggests normal superficial radial nerve function, which is not relevant to ulnar neuropathy.

Question 2890

Topic: Wrist & Carpus

A 20-year-old gymnast presents with chronic ulnar-sided wrist pain, clicking, and instability after a fall. Examination reveals tenderness over the dorsal TFCC, a positive grind test, and pain with resisted supination. Radiographs are normal. MRI shows a Palmer Type 1B tear of the TFCC. What is the MOST appropriate treatment for this patient?

. Immobilization in a long arm cast for 6 weeks
. Ulnar shortening osteotomy
. Arthroscopic debridement of the TFCC tear
. Arthroscopic repair of the TFCC tear
. Excision of the ulnar styloid

Correct Answer & Explanation

. Immobilization in a long arm cast for 6 weeks

Explanation

A Palmer Type 1B tear of the TFCC involves a traumatic avulsion of the TFCC from its ulnar insertion, often associated with instability. In a young, active individual like a gymnast, restoration of TFCC stability is paramount to prevent chronic pain, instability, and degenerative changes. Arthroscopic repair, specifically reattachment of the avulsed peripheral TFCC, is the preferred treatment for this type of tear, especially if unstable. Immobilization might be tried initially for stable peripheral tears, but with chronic symptoms and instability, repair is indicated. Ulnar shortening osteotomy is indicated for ulnar positive variance with central (Type 1A) or degenerative (Type 2) tears, not primary traumatic peripheral tears with instability. Arthroscopic debridement is usually for stable, central TFCC tears (Type 1A) or degenerative tears (Type 2). Excision of the ulnar styloid is not a standard treatment for TFCC tears.

Question 2891

Topic: Nerve & Tendon

A rock climber presents with pain and swelling in the palm and volar aspect of his ring finger. He reports hearing a "pop" during a difficult climb. Examination reveals tenderness along the A2 pulley, bowstringing of the flexor tendons with active flexion, and decreased grip strength. Which of the following is the MOST appropriate initial management?

. Surgical repair of the A2 pulley
. Corticosteroid injection into the pulley sheath
. Immobilization in extension with a dorsal block splint
. Rest, ice, compression, and a pulley support splint
. Tenolysis of the flexor tendons

Correct Answer & Explanation

. Surgical repair of the A2 pulley

Explanation

The symptoms (pop, pain, tenderness, bowstringing of flexor tendons) are classic for a rupture of the A2 pulley, a common injury in rock climbers. While surgical repair can be indicated for complete multiple pulley ruptures or severe single pulley ruptures causing significant functional deficit, the initial management for isolated or partial A2 pulley ruptures is typically conservative. This includes rest, ice, compression, and importantly, a specialized pulley support splint (e.g., ring splint or tape) worn during activities to prevent further bowstringing and allow healing. This allows the flexor tendons to glide more efficiently and reduces the load on the healing pulley. Corticosteroid injections are not indicated. Immobilization in extension would lead to stiffness and is contrary to the goal of allowing controlled motion while preventing bowstringing. Tenolysis is for adhesions, not acute pulley ruptures.

Question 2892

Topic: Wrist & Carpus

A 40-year-old male sustains a Galeazzi fracture-dislocation. Radiographs show a fracture of the distal third of the radius with associated dorsal dislocation of the distal radioulnar joint (DRUJ). He is an active laborer. What is the MOST appropriate treatment for this injury?

. Closed reduction and long arm cast immobilization
. Open reduction and internal fixation (ORIF) of the radial shaft fracture only
. ORIF of the radial shaft fracture with DRUJ stabilization
. External fixation of the radius with DRUJ management
. Observation and early range of motion

Correct Answer & Explanation

. Closed reduction and long arm cast immobilization

Explanation

A Galeazzi fracture-dislocation (fracture of the distal 1/3 of the radius with associated DRUJ dislocation) is considered an unstable injury. In adults, it almost always requires surgical stabilization. The primary goal is stable fixation of the radial shaft fracture, which, when anatomically reduced, often allows for spontaneous reduction and stabilization of the DRUJ. However, the DRUJ must be carefully assessed intraoperatively for stability after radial fixation. If the DRUJ remains unstable, it requires specific stabilization (e.g., temporary pin fixation across the DRUJ, TFCC repair if indicated). Closed reduction and casting alone are highly prone to failure in adults. ORIF of the radius alone without considering DRUJ stability is incomplete. External fixation is generally reserved for open fractures, severe soft tissue injuries, or highly comminuted fractures not amenable to ORIF. Observation is inappropriate.

Question 2893

Topic: 7. Hand and Wrist

A 40-year-old administrative assistant complains of progressive numbness, tingling, and burning pain in her thumb, index, middle finger, and radial half of the ring finger, worse at night. She has noted dropping objects due to weakness. Examination reveals thenar atrophy, a positive Phalen's test, and a positive Tinel's sign at the wrist. Nerve conduction studies confirm severe carpal tunnel syndrome. What is the MOST appropriate next step in management?

. Wrist splinting at night
. Corticosteroid injection into the carpal tunnel
. Oral NSAIDs
. Endoscopic carpal tunnel release
. Observation and activity modification

Correct Answer & Explanation

. Wrist splinting at night

Explanation

The patient's symptoms (classic median nerve distribution paresthesias, night pain, dropping objects, thenar atrophy) and positive provocative tests, confirmed by severe nerve conduction study findings, indicate severe carpal tunnel syndrome. The presence of thenar atrophy signifies advanced motor involvement, indicating that conservative measures (splinting, injections, NSAIDs, activity modification) are unlikely to be effective and surgical decompression is warranted to prevent irreversible nerve damage and motor loss. Both open and endoscopic carpal tunnel release are effective surgical options, with endoscopic offering potentially faster recovery and less scar tenderness for some patients. Given the severity, surgery is the most appropriate next step.

Question 2894

Topic: 7. Hand and Wrist

A 45-year-old accountant complains of chronic radial-sided wrist pain, clicking, and weakness after a fall several years ago. Examination reveals tenderness over the scapholunate interval, a positive Watson (scaphoid shift) test, and weakness of grip. Radiographs show a widened scapholunate interval (>3mm) and dorsal intercalated segmental instability (DISI) on lateral views. Which of the following is the MOST appropriate treatment for this condition?

. Wrist arthrodesis
. Scaphoid nonunion repair with bone graft
. Proximal row carpectomy (PRC)
. Scapholunate ligament repair/reconstruction
. Radial styloidectomy

Correct Answer & Explanation

. Wrist arthrodesis

Explanation

The patient's symptoms and signs (chronic radial-sided wrist pain, clicking, tenderness over SL interval, positive Watson test, widened SL interval, DISI deformity) are classic for chronic scapholunate (SL) dissociation. This injury involves rupture of the scapholunate ligament, leading to carpal instability. For chronic, symptomatic, and correctable SL dissociation without significant degenerative changes (e.g., SLAC wrist Stage I/II), scapholunate ligament repair or reconstruction (e.g., using a portion of the FCR or dorsal capsular tissue) is the most appropriate surgical intervention to restore carpal kinematics and prevent progression to SLAC wrist. Wrist arthrodesis is a salvage procedure for end-stage arthritis. Scaphoid nonunion repair is for scaphoid fractures. Proximal row carpectomy and radial styloidectomy are for more advanced degenerative changes (SLAC wrist) where the SL dissociation has led to significant arthritis.

Question 2895

Topic: Hand Trauma & Infection

A gardener presents with an acutely painful, swollen, and red index finger. He describes a puncture wound from a thorn 3 days prior. The finger is held in slight flexion, and any attempt at passive extension causes severe pain. There is tenderness along the entire course of the flexor tendon sheath. What is the MOST likely diagnosis?

. Cellulitis
. Felon
. Paronychia
. Septic arthritis
. Suppurative flexor tenosynovitis (SFT)

Correct Answer & Explanation

. Cellulitis

Explanation

The patient's presentation precisely describes Kanavel's Four Cardinal Signs of Suppurative Flexor Tenosynovitis (SFT): 1) Uniform swelling of the digit, 2) Flexed posture of the digit, 3) Exquisite tenderness along the course of the flexor tendon sheath, and 4) Severe pain on passive extension. SFT is a surgical emergency requiring urgent incision and drainage to prevent tendon necrosis and irreversible stiffness. Cellulitis is a diffuse infection without the specific tendon sheath involvement. A felon is a pulp space infection. Paronychia is a nail fold infection. Septic arthritis affects the joint, not primarily the tendon sheath, although it can coexist.

Question 2896

Topic: 7. Hand and Wrist

A 30-year-old heavy equipment operator presents with chronic dorsal wrist pain and stiffness, particularly with heavy gripping. Radiographs show increased sclerosis and collapse of the lunate bone. MRI confirms avascular necrosis of the lunate (Kienbock's disease, Lichtman Stage IIIb). The patient has positive ulnar variance. Which of the following surgical procedures is MOST appropriate?

. Proximal row carpectomy (PRC)
. Wrist arthrodesis
. Radial shortening osteotomy
. Capitate shortening osteotomy
. Lunate excision

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

Kienbock's disease is avascular necrosis of the lunate. The patient has Lichtman Stage IIIb disease (lunate collapse with fixed carpal collapse, but without widespread arthritic changes). The presence of positive ulnar variance (ulna longer than the radius) is a predisposing factor, increasing load on the lunate. Therefore, a radial shortening osteotomy is the MOST appropriate procedure in this scenario. It decompresses the lunate by reducing the load from the radius, promoting revascularization and preventing further collapse. Proximal row carpectomy or wrist arthrodesis are salvage procedures for end-stage arthritis (Lichtman Stage IV). Capitate shortening osteotomy is indicated for negative ulnar variance. Lunate excision alone is not typically performed due to carpal instability.

Question 2897

Topic: 7. Hand and Wrist

A 25-year-old male falls on an outstretched hand and presents with radial-sided wrist pain. Examination reveals tenderness in the anatomical snuffbox and with scaphoid tubercle palpation. Initial radiographs are unremarkable. What is the MOST appropriate next step in management?

. Discharge with instructions for RICE and return if symptoms persist
. Short arm cast immobilization and repeat radiographs in 2 weeks
. MRI of the wrist
. CT scan of the wrist
. Emergency open reduction and internal fixation

Correct Answer & Explanation

. Discharge with instructions for RICE and return if symptoms persist

Explanation

A fall on an outstretched hand with anatomical snuffbox tenderness strongly suggests a scaphoid fracture, even if initial radiographs are negative (occult scaphoid fracture). Due to the high risk of avascular necrosis and nonunion, definitive diagnosis and management are crucial. The MOST appropriate initial step is to immobilize the wrist (typically in a short arm thumb spica cast) and repeat radiographs in 10-14 days. During this time, the fracture line may become visible due to bone resorption. An MRI or CT scan can be used earlier if there is a high suspicion and need for immediate definitive diagnosis, especially for high-risk patients (e.g., athletes, patients with compliance concerns). However, immobilization and delayed radiographs are a common and appropriate initial management strategy. Emergency ORIF is reserved for displaced fractures or those with high risk of nonunion. Discharging without immobilization is a high-risk approach for a potential scaphoid fracture.

Question 2898

Topic: 7. Hand and Wrist

A 20-year-old basketball player jams his finger during a game. He presents with pain and inability to actively extend his distal interphalangeal (DIP) joint, which rests in 40 degrees of flexion. Passive extension is full. Radiographs are normal. What is the MOST appropriate initial management?

. Surgical repair of the extensor tendon
. Closed reduction and K-wire fixation
. DIP joint fusion
. Continuous DIP joint extension splinting for 6-8 weeks
. Buddy taping to an adjacent finger

Correct Answer & Explanation

. Surgical repair of the extensor tendon

Explanation

The patient presents with a classic mallet finger deformity (flexion deformity of the DIP joint with inability to actively extend, full passive extension, normal radiographs), indicating an extensor tendon avulsion from the distal phalanx without associated fracture (Stack Grade I). The treatment of choice for acute mallet finger without significant bone avulsion is continuous DIP joint extension splinting for 6-8 weeks, followed by nighttime splinting for another 2-4 weeks. This allows the tendon to heal in a shortened position. Surgical repair is rarely indicated for mallet fingers without bone avulsion, reserved for irreducible fracture-mallets or chronic cases with extensor lag. Closed reduction and K-wire fixation is for fracture-mallets. DIP joint fusion is a salvage. Buddy taping is insufficient.

Question 2899

Topic: 7. Hand and Wrist

A 30-year-old female presents with a recurrent dorsal wrist ganglion cyst 6 months after surgical excision. The previous surgery involved a standard open excision. What is the MOST likely reason for recurrence?

. Incomplete excision of the cyst wall and stalk
. Formation of a new cyst in an adjacent location
. Infection of the surgical site
. Poor wound healing
. Aggressive physical therapy post-operatively

Correct Answer & Explanation

. Incomplete excision of the cyst wall and stalk

Explanation

The most common reason for recurrence of a ganglion cyst after surgical excision is incomplete removal of the stalk (pedicle) that connects the cyst to the joint capsule or tendon sheath. If the connection point is not excised, the synovial fluid continues to egress, leading to reformation of the cyst. While new cysts can form, or poor wound healing can occur, incomplete excision of the stalk is the primary anatomical reason for recurrence. Infection and aggressive physical therapy are less likely to be direct causes of recurrence, although infection can lead to other complications. The goal of ganglion surgery is to resect the cyst and its base down to the joint capsule.

Question 2900

Topic: 7. Hand and Wrist

A 20-year-old male presents with pain and swelling in his small finger after punching a wall. Radiographs confirm a displaced, angulated fracture of the small finger metacarpal neck (Boxer's fracture) with 50 degrees of volar angulation. The patient has no rotational deformity and good grip strength. Which of the following is the MOST appropriate management?

. Open reduction and internal fixation (ORIF)
. Closed reduction and ulnar gutter splinting
. Percutaneous pinning
. Observation and early range of motion
. Buddy taping to the ring finger

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF)

Explanation

A Boxer's fracture is a fracture of the fifth metacarpal neck. While significant angulation can occur, the tolerable angulation in the small finger metacarpal is generally up to 70 degrees due to the compensatory mobility of the carpometacarpal (CMC) joint. However, 50 degrees of volar angulation is often cosmetically unappealing and may cause issues with grip. Closed reduction to decrease the angulation to an acceptable level (typically less than 40-50 degrees) followed by immobilization in an ulnar gutter splint (with the MCP joints flexed at 70-90 degrees) is the standard treatment. Rotational deformity is critical and must be corrected. ORIF or percutaneous pinning are reserved for irreducible fractures, rotational deformities, excessive angulation that cannot be corrected, or multiple metacarpal fractures. Observation or buddy taping are insufficient for a displaced, angulated fracture.

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