Return to sport after metacarpal and phalangeal fractures: a systematic review and evidence appraisal

Key points

1. 01100% return-to-sport rate across all 8 included studies
2. 02Metacarpal fractures: mean return 21.9 days (95% CI 15.0-28.7 days); phalangeal fractures: mean return 30.6 days (95% CI 17.5-43.9 days)
3. 03Operatively managed metacarpal fractures had longer mean return time than nonoperatively managed ones (28.5 vs 22.0 days), but all studies were retrospective and none were randomized
4. 04All 8 studies were rated fair or poor quality with significant confounding risk
5. 0597% of patients were male, and nearly half of injuries came from American football

How it was conducted

Design

Systematic review and meta-analysis (PRISMA-compliant, PROSPERO registered CRD42019152448)

Databases

MEDLINE, Embase, EMCARE, CINAHL (searched to December 2019)

Included studies

8 retrospective cohort studies; no randomized controlled trials

Participants

234 patients (184 metacarpal, 50 phalangeal fractures); 97% male; mean age 21 years

Primary outcome

Time from definitive treatment to return to preinjury level of competition

Quality assessment

NIH tool for observational studies; GRADE ratings assigned to pooled estimates

What they found

• Return-to-sport rate: 100% across all 8 studies
• Pooled mean return-to-sport time for phalangeal fractures: 30.6 days (95% CI 17.5-43.9 days)
• Pooled mean return-to-sport time for metacarpal fractures: 21.9 days (95% CI 15.0-28.7 days)
• Operatively managed metacarpal fractures: pooled mean 28.5 days (95% CI 16.0-40.9 days); GRADE rating very low
• Nonoperatively managed metacarpal fractures: pooled mean 22.0 days (95% CI 11.5-32.3 days); GRADE rating very low
• Operatively managed phalangeal fractures: pooled mean 35.1 days (95% CI 14.0-56.0 days); GRADE rating very low
• One comparative study (Morse et al.) found significantly longer return time for surgically treated vs nonoperatively treated metacarpal fractures (56.7 +/- 26.3 days vs 26.3 +/- 12.1 days; P < .01)
• Radiographic union achieved in all patients across 5 studies that reported it
• Complications in operatively managed patients: persistent discomfort at surgical site (2/78 metacarpal), wound dehiscence (2/30 phalangeal)

Limitations

• All 8 studies were retrospective cohorts with fair or poor quality; no randomized controlled trials were identified
• Severity of injury likely confounds the operative vs nonoperative comparison, as worse fractures more often required surgery
• Cohort heterogeneity across sports, competition levels, rehabilitation protocols, and outcome measures limits generalizability
• 97% male participants and predominance of American football and basketball players limit applicability to other populations and sports

Why it matters

For patients

Athletes who fracture a metacarpal or phalangeal bone can expect to return to their prior competition level, typically within 3 to 5 weeks, though the best treatment choice depends on fracture severity and sport requirements.

For clinicians

Current evidence is insufficient to recommend operative over nonoperative management for faster return to sport; treatment decisions should be individualized based on fracture pattern, sport demands, and athlete context rather than return-time data alone.

For readers

This review highlights a critical evidence gap: despite these fractures being common in sports, only 8 low-quality retrospective studies exist, and higher-quality research is needed before firm management guidelines can be issued.