significantly angulated or displaced fractures can often be predicted based on examination Most nondisplaced shaft fractures can be managed with immobilization, though fractures with significant displacement may require operative stabilization FIGURE 109.13 Anteroposterior radiograph of the hand depicting a displaced fifth metacarpal neck fracture (Courtesy of Children’s Orthopaedic Surgery Foundation.) Fractures of the metacarpals are least likely to occur in the base of the bone When these occur, they usually involve the small finger There will be significant pain and dorsal edema, which can make accurate diagnosis challenging Plain radiograph imaging can be difficult to interpret and at times will require CT scan to fully characterize the injury Minimally or nondisplaced fractures are generally managed with a splint or cast Displaced fractures often require closed reduction, possible pinning, and subsequent casting Carpometacarpal dislocations alone or in conjunction with a base fracture are unstable and often require operative stabilization ( Fig 109.14 ) Bennett fractures, or intra-articular fractures of the base of the thumb metacarpal, mandate special attention, as the thumb carpometacarpal joint is critical for full use of this digit ( Fig 109.15 ) Similarly, Rolando fractures, comminuted fractures of the base of the thumb metacarpal, also require careful attention These fractures can be addressed temporarily with a thumb spica splint and timely referral CARPALS CLINICAL PEARLS AND PITFALLS The scaphoid is the most commonly fractured carpal bone Ligamentous injuries and dislocations can be subtle but have significant morbidity FIGURE 109.14 Radiographs demonstrating carpometacarpal dislocation (Courtesy of Children’s Orthopaedic Surgery Foundation.) Clinical Considerations Clinical Recognition The incidence of carpal fractures is relatively low in children, although increasing awareness has led to improved recognition In infancy, the carpals are completely cartilaginous and are nearly immune to injury They progressively ossify beginning with the capitate The scaphoid is by far the most common fractured carpal bone, with most fractures occurring in late childhood and adolescence Falls are the most frequent cause FIGURE 109.15 Radiographs of the thumb depicting a Bennett fracture (Courtesy of Children’s Orthopaedic Surgery Foundation.) Initial Assessment and Management Physical examination requires attention to edema, range of motion, and point tenderness to localize carpal injuries Snuffbox tenderness is a useful tool for detecting scaphoid fractures Pain with axial thumb compression can also be a sign of scaphoid injury Radiographs are obviously limited in infancy and early childhood because of the lack of ossification As the patient ages and the carpals are progressively ossifying, comparison with the contralateral side may be of benefit Dedicated scaphoid views or computed tomography may help to identify some fractures not seen on routine hand or wrist films Nondisplaced scaphoid fractures may not be obvious on initial x-rays but will be visible on repeat imaging performed weeks following the injury A missed scaphoid injury can lead to significant morbidity