Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Metacarpal Bones


Related Terms

  • Bennett's Fracture
  • Boxer's Fracture
  • Broken Hand
  • Rolando's Fracture

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Hand Therapist
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

Disability depends on whether the dominant or nondominant hand is involved, work requirements, the fingers involved, severity of injury, and the presence of complications.

Medical Codes

ICD-9-CM:
815.00 - Closed Fracture of Metacarpal Bone(s), Site Unspecified
815.01 - Closed Fracture of Base of Thumb Metacarpal
815.02 - Closed Fracture of Base of Other Metacarpal Bone(s)
815.03 - Closed Fracture of Shaft of Metacarpal Bone(s)
815.04 - Closed Fracture of Neck of Metacarpal Bone(s)
815.09 - Closed Fracture of Multiple Sites of Metacarpus
815.10 - Open Fracture of Metacarpal Bone(s), Site Unspecified
815.11 - Open Fracture of Base of Thumb Metacarpal Bone; Bennetts Fracture
815.12 - Open Fracture of Base of Other Metacarpal Bone(s)
815.13 - Open Fracture of Shaft of Metacarpal Bone(s)
815.14 - Open Fracture of Neck of Metacarpal Bone(s)
815.19 - Open Fracture of Multiple Sites of Metacarpus

Overview

© Reed Group
A metacarpal fracture is a break in one of the five metacarpal bones of either hand. These long, thin bones are located between the carpal bones in the wrist and the phalanges in the digits. Metacarpal fractures are categorized as being fractures of the head, neck, shaft, and base (from distal at the metacarpal phalangeal joint to proximal at the wrist). The most common metacarpal fracture is a fracture of the neck of the fifth metacarpal, commonly called a boxer's fracture.

Fractures of the thumb (first metacarpal) are less common. Most thumb metacarpal fractures occur at the base because of the increased mobility of the thumb, rather than at the neck. These unique fractures are labeled as Bennett's fracture and Rolando's fracture. Rolando's fracture is an intra-articular fracture of the base of the first metacarpal where the bone is broken into three or more pieces at the fracture site (comminuted); Bennett's fracture is a noncomminuted fracture in the same location involving the volar anterior oblique ligament. Both are usually unstable and require surgery.

Most metacarpal fractures of the fingers are caused by a direct forceful blow, such as punching a solid object with a closed fist, or having a heavy object land on the hand. The thumb metacarpal fractures are usually caused by an axial blow directed against the partially flexed metacarpal.

Incidence and Prevalence: Metacarpal and phalangeal fractures make up approximately 10% of all fractures and approximately 30% to 40% of all hand fractures; fractures of the fifth metacarpal neck account for 10% of all hand fractures (Dye). While many fractures are treated in outpatient settings and may not be reflected in incidence rates, the lifetime incidence of metacarpal fracture in the US is estimated to be 2.5% (Dye).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals who compete in contact sports such as football and boxing are at increased risk for metacarpal fracture. This is primarily because the hand is often exposed (i.e., held out in front of the body or used to block other athletes) and is relatively unprotected. Other individuals at high risk for this type of fracture are those who have a history of bone or joint disease (e.g., osteoporosis) or who have nutritional deficiencies (e.g., calcium deficiency). Individuals who work in construction or factories have an increased risk of fracture.

Males sustain more metacarpal fractures than females by a 3 to 1 ratio. Most metacarpal fractures occur in the active and working population, particularly young adults and adolescents.

Source: Medical Disability Advisor



Diagnosis

History: Most fractures result directly from trauma. Individuals will recall or exhibit a recent injury and complain of severe hand pain, as well as swelling of soft tissue (edema) around the fracture site. Hand function is usually immediately impaired.

Physical exam: Examination may reveal a visible deformity if the fracture is displaced. Localized swelling and tenderness to touch may be noted around the fracture site. Decreased motion is usually present. Decreased grip strength may be noted. Any delay in seeking treatment may have resulted in more generalized pain and swelling. A complete neurovascular exam of the arm, hand, and fingers may be performed.

Tests: Routine x-rays include three views (anteroposterior [AP], lateral, and oblique) to properly assess angulation of the fracture fragments as well as involved joint surfaces. CT scans may be ordered to evaluate the metacarpal-carpal joints in complicated fractures.

Source: Medical Disability Advisor



Treatment

These fractures must heal properly to maintain good hand mechanics. The base of the thumb metacarpal fracture is usually unstable and therefore frequently requires open reduction and internal fixation (surgery) as an outpatient. The second and third metacarpals (index and middle finger) act as anchors for the palmar arch and therefore anatomical alignment is very important. Progressively more angulation can be tolerated with fractures of the fourth and fifth metacarpals (ring and little finger). However, rotation and excessive shortening should be avoided in any of fracture of the metacarpals. Again, normal position (anatomical alignment) is the goal of treatment.

Most metacarpal fractures require only limited immobilization, and early return to movement is encouraged (Jupiter). Simple neck fractures of the 5th metacarpal may be managed with functional treatment such as taping, functional bracing, strapping, or ulnar splinting. This may have the advantage of decreasing stiffness after initial treatment (Hegmann). Simple closed fractures may do better with range of motion beginning within 21 days of the initial injury as long as the fracture site is protected (Frontera). Early motion of adjacent joints in closed simple metacarpal fractures may increase range of motion and strength and lead to earlier return to work (Wright).

The fractured metacarpal(s) must be realigned to their normal anatomic position either without surgery (closed reduction) or using surgical techniques (open reduction). With open reduction, metal wires, pins, or screws may be necessary to maintain the position once obtained (open reduction, internal fixation [ORIF]). Open reduction has the advantage of being able to obtain a nearly normal position of the fracture fragments, and internal fixation allows early gentle motion of the fingers in physical therapy. Casts, splints, and braces often are used to maintain position, whether the fracture is treated surgically or nonsurgically. Metacarpal neck fractures rarely require reduction or ORIF when angulation is not excessive. The hand often is placed in a hand-based cast or splint, with "buddy taping" as a supporting technique. Buddy taping involves taping the finger whose metacarpal is fractured to an adjacent finger with athletic tape or similar material. This treatment is followed by early initiation of range of motion exercises. Follow-up x-rays at 5 to 7 days usually are done to rule out displacement or re-angulation.

Severe fractures with multiple pieces (comminuted) may require the use of an external metal device that maintains the position of the fragments while allowing motion of the joints (external fixator). Any open wounds also require antibiotic treatment and follow-up wound care. Individuals with massive crushing injuries to the hand may be hospitalized to control swelling and treat or prevent infection. Fractures that also have injury to blood vessels or nerves may require hospitalization after surgery.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Middle and Proximal Phalangeal and Metacarpal Fractures
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

With proper treatment and good rehabilitation, the prognosis is good to excellent for both closed and open reduction of cases with only metacarpal fractures. Metacarpal fractures that are associated with other fractures such as those that involve the proximal phalangeal joint (PIP) have poorer outcomes. Uncomplicated fractures heal in 6 to 12 weeks. Any complication will delay recovery and result in loss of function.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation is related to the location and type of fracture and the duration of immobilization. Rehabilitation may be administered by a physical therapist, occupational therapist, or hand therapist. Hand dominance and the involved extremity will greatly influence the individual's degree of disability. The main focus of rehabilitation should emphasize restoring full range of motion and strength while maintaining independence in as many of the individual's activities of daily living as possible. Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative) (Wright; Purdy; McNemar). The treating physician will specify when it is safe to begin each step of rehabilitation (usually range of motion first, followed later by strengthening, edema control, and sometimes desensitization).

Bone healing may occur within 6 to 12 weeks, but bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Metacarpal Bones
Occupational / Hand / Physical TherapistUp to 10 visits within 6 weeks
Surgical
SpecialistFracture, Metacarpal Bones
Occupational / Hand / Physical TherapistUp to 12 visits within 6 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Possible complications of metacarpal fractures include malunion, which will cause pain on gripping; nonunion, which will necessitate reconstructive surgery; metacarpophalangeal joint extension contractures; intrinsic muscle contractures; infection (especially pin tract); tendon adherence; and refracture.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations will vary according to the severity of the fracture and the amount of exertion or dexterity required for the individual's job. Full use of the injured hand and fingers may need to be restricted until the fracture has healed. Rest periods to allow elevation of the hand are important to avoid complications. Any work task that requires two hands may need to be limited for 4 to 12 weeks during healing and then resumed gradually during rehabilitation. Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period. If the dominant arm or hand is affected, the individual may be unable to write legibly or type well. In some cases, alternatives to a standard keyboard, such as speech recognition software or one-handed keyboards, may be appropriate accommodations.

Fractures of the thumb generally require an average of 2 weeks longer to recover than fractures of the other metacarpals before use in medium and heavy grasping, due to the higher muscular forces that occur across the thumb during heavy activity. Since the thumb is used in most hand functions, and since many hand functions can be done using only some of the fingers, thumb fractures are much more likely to limit hand function. Fractures in multiple digits typically involve much higher forces (more violent injuries) and thus have more soft tissue damage. Thus function is increasingly limited both by more digits being involved and by more severe injury in each digit.

Risk: Just as in the case of finger or thumb fractures, risk is a consideration early after injury until the fracture is solidly healed. Activity that overstresses the fracture site can cause loss of position (deformity) or delayed union/non-union to occur. Even in fractures surgically “stabilized” with hardware, such as pins or screws, the bone is not as strong as it will be once it is healed, and overstress can cause the pins and / or screws to fail, allowing the fracture to deform. Once x-rays show the fracture is solidly healed, then risk to the fracture with activity is no longer an issue. If lack of capacity (such as weak grip or pinch strength, as well as limited hand motion or dexterity) is present, jobs involving risk (e.g. using hand-held power tools) may lead to injury to other body parts, or to co-workers, until strength and motion recover to levels that are adequate for the work function (e.g. to control the hand held power tool).

Capacity: Weak grip or pinch strength, limited hand motion, and limited dexterity are typically present after hand fractures, even after the fracture is solidly healed. It may take up to 6 months for these to improve to near their maximal level of recovery.

Tolerance: Pain is common with finger and thumb metacarpal fractures during healing. Tolerance is determined by the specific activities and rewards (such as salary or fun) versus the cost (such as pain).

Accommodations: Accommodations are the key to one's ability to return to activities. For example, the football player can be accommodated by having foam padding applied over his cast in order to play football. By contrast, a cook who has to wash his hands may not be able to return to work with a cast on.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is typically achieved within 2 to 84 days of finger and thumb fractures, although Permanent Impairment may occur and can be determined once strength, motion, and dexterity are stable over a 56 day period.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual present with symptoms consistent with a metacarpal bone fracture?
  • Were x-rays done to confirm the diagnosis?
  • If the diagnosis was uncertain, were other conditions with similar symptoms ruled out?

Regarding treatment:

  • Was treatment appropriate to the type and location of fracture?
  • Did the fracture heal? Is the fracture in good position or is malunion (poor position of the fracture pieces) limiting hand function?
  • Was individual's pain adequately managed?
  • Did individual receive occupational or physical therapy?

Regarding prognosis:

  • Has adequate time elapsed for healing?
  • Did individual actively participate in the recommended occupational or physical therapy?
  • Would individual benefit from therapy with a certified hand therapist?
  • Would individual benefit from consultation with a specialist, such as an orthopedic surgeon, hand surgeon, occupational therapist, physical therapist, or physiatrist?
  • Did individual suffer any associated complications that may contribute to a delayed or incomplete recovery?
  • Does individual have an underlying condition, such as degenerative arthritis, osteoporosis, calcium deficiency, Paget's disease, and tumors or cysts of the affected bones that may affect recovery?
  • Has change of duties or temporary job reassignment been considered as appropriate?

Source: Medical Disability Advisor



References

Cited

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Dell, P. C., and R. B. Dell. "Management of Carpal Fractures and Dislocations." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. 1171-1184.

Dye, T. Michael. "Metacarpal Fractures." eMedicine. Ed. Harris Gellman. 17 Feb. 2012. Medscape. 22 Jan. 2013 <http://emedicine.medscape.com/article/1239721-overview>.

Frontera, Walter E. "Chapter 27 - Hand and Wrist Injuries." Clinical Sports Medicine: Medical Management and Rehabilitation. 1st ed. Saunders, Elsevier, 2006.

Hardy, M. A., ed. "Principles of Metacarpal and Phalangeal Fracture Management. A Review of Rehabilitation Concepts.." Journal of Orthopadedic Sports Physical Therapy 34 (2004): 78-99.

Hegmann, Kurt T., et al., eds. "Chapter 11: Hand, Wrist and Forearm Disorders." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 2008 Revision 2nd ed. ACOEM, 2008. 627-652.

Jupiter, Jesse B., Terry S. Axelrod, and Mark Belsky. "Chapter 38 - Fractures and Dislocations of the hand." Skeletal Trauma. Eds. Bruce D. Browner, et al. 4th ed. W.B. Saunders, 2008.

McNemar, T. B., J. W. Howell, and E. Chang. "Management of Metacarpal Fractures." Journal of Hand Therapy 16 2 (2003): 143-151. National Center for Biotechnology Information. National Library of Medicine. 28 Oct. 2010 <PMID: 12755165>.

Meals, Roy A., and G. Neil, eds. "Extraarticular Hand Fractures in Adults: A Review of New Developments." Clinical Orthopaedics and Related Research 455 133-145.

Purdy, B. A., and R. L. Wilson. "Management of Nonarticular Fractures of the Hand." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002.

Salter, Robert, ed. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999.

Wright, Phillip E. "Chapter 61 - The hand." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Source: Medical Disability Advisor






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