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Fifth metacarpal bone

The fifth metacarpal bone is the most ulnar (medial) of the five elongated metacarpal bones that constitute the skeletal framework of the human palm, specifically associating with the little finger (fifth digit).^[1] This long bone features a broad, triangular base proximally, a narrow, prism-shaped shaft, and a rounded head distally, providing structural support for hand movements and grip.^[2] It measures approximately 5.2-5.5 cm in length in adults, making it one of the shorter metacarpals, and plays a key role in bridging the carpal bones of the wrist to the phalanges of the fingers.^[3]^[4] Structurally, the base of the fifth metacarpal articulates with the hamate carpal bone at the fifth carpometacarpal joint and shares a partial articulation with the base of the fourth metacarpal, allowing limited mobility including abduction and adduction of the little finger.^[1] The concave medial and lateral surfaces of the shaft serve as attachment sites for the dorsal and palmar interossei muscles, which facilitate finger abduction and adduction, while the base also receives the insertion of the extensor carpi ulnaris tendon and the opponens digiti minimi muscle.^[2]^[5] The head forms a convex condyle that articulates with the proximal phalanx at the metacarpophalangeal joint, enabling flexion, extension, and opposition movements essential for hand dexterity.^[1] Blood supply to the bone derives primarily from the dorsal metacarpal arteries (branches of the ulnar artery) and the deep palmar arch (from the ulnar artery), with innervation provided by the ulnar nerve for both sensory and motor functions related to the hypothenar eminence and interossei.^[1]^[6] Functionally, the fifth metacarpal contributes to the hand's overall stability and power grip, particularly in activities requiring ulnar deviation and fine motor control of the little finger, such as pinching or manipulating objects.^[3] Unlike the more rigid second and third metacarpals, the fifth metacarpal's carpometacarpal joint permits greater mobility, enhancing the hand's adaptability in grasping and tool use.^[2] Clinically, it is prone to fractures at the neck—commonly known as a boxer's fracture—due to its exposure during clenched-fist impacts, which can lead to angulation, shortening, and impaired hand function if untreated.^[3]

Anatomy

Location and overview

The fifth metacarpal bone is the most medial and second-shortest of the five metacarpal bones in the human hand, serving as the primary skeletal support for the little finger (digit V).^[7] It forms part of the palm's framework, positioned alongside the other metacarpals that connect the wrist to the fingers.^[2] Located on the ulnar (medial) side of the hand, the fifth metacarpal extends proximally from its articulation with the carpal bones of the wrist—specifically the hamate—to distally join the base of the proximal phalanx of the little finger.^[7] This positioning places it at the edge of the palm, facilitating the hand's overall mobility and grip capabilities. In adults, it measures approximately 5.4 cm in length on average, exhibiting a slender build that contrasts with the more robust central metacarpals (II–IV), thereby enabling enhanced flexibility and range of motion for the little finger.^[8] The bone's orientation runs obliquely from a proximal-medial to distal-lateral direction, which supports the hand's structural integrity by contributing to both the transverse arch (across the palm) and the longitudinal arch (along the fingers).^[2] This oblique alignment, more pronounced than in the index or middle metacarpals, allows for greater abduction and adduction of the little finger, essential for fine motor tasks.^[7]

Structure

The fifth metacarpal bone consists of a proximal base, an elongated shaft, and a distal head.^[7] The base represents the expanded proximal end, featuring a concavo-convex facet on its proximal surface for articulation with the hamate bone, a smaller facet on its radial (lateral) surface for articulation with the base of the fourth metacarpal bone, and a prominent tubercle on its ulnar (medial) surface for attachment of the extensor carpi ulnaris tendon.^[9] The shaft, or body, exhibits a triangular cross-section with dorsal convexity, providing structural support and sites for muscular attachments. Its dorsal surface is divided by an oblique ridge extending from near the ulnar aspect of the base to the radial aspect of the head; this ridge separates a lateral area for attachment of the fourth dorsal interosseous muscle from a medial, smooth triangular region covered by the tendon of the extensor digiti minimi. The palmar surface includes a lateral groove serving as the origin for the third palmar interosseous muscle and a medial region for insertion of the opponens digiti minimi muscle. Nutrient foramina, typically one per bone and located in the middle third of the shaft, enter primarily from the lateral surface to supply the medullary cavity.^[9]^[7]^[10] The head forms the rounded distal end, bearing a convex articular surface—often described as having a double-faceted configuration—for articulation with the base of the proximal phalanx of the little finger; relative to the heads of the second and third metacarpals, it is more flattened, facilitating enhanced mobility at the metacarpophalangeal joint. Compared to the second and third metacarpals, the fifth metacarpal demonstrates greater overall curvature, contributing to the flexibility of the ulnar border of the hand.^[7]^[11]

Articulations

The fifth metacarpal bone participates in three primary articulations that facilitate hand mobility and stability. Proximally, its base forms the fifth carpometacarpal (CMC) joint with the distal surface of the hamate bone, a saddle-shaped synovial joint characterized by a transversely concave and coronally convex articular surface with a beveled edge.^[12] This configuration allows for flexion (approximately 20°), extension, and limited abduction/adduction, with some internal-external rotation observed in cadaveric studies.^[12] The joint is reinforced by dorsal and palmar carpometacarpal ligaments originating from the hamate, as well as pisohamate and pisometacarpal ligaments that connect the pisiform to the hamate hook and fifth metacarpal base.^[12]^[13] Laterally, the base of the fifth metacarpal articulates with the base of the fourth metacarpal at the fourth-fifth intermetacarpal joint, a plane synovial joint supported by strong interosseous and intermetacarpal ligaments that permit limited gliding motions and maintain the transverse metacarpal arch.^[13]^[14] The dorsal intermetacarpal ligament specifically connects the dorsal surfaces of these adjacent metacarpals, enhancing stability during hand movements.^[2] Distally, the head of the fifth metacarpal articulates with the base of the proximal phalanx of the little finger at the fifth metacarpophalangeal (MCP) joint, a condyloid (shallow ball-and-socket) synovial joint that enables flexion up to 90°, extension, abduction, adduction, and circumduction.^[15] Stability is provided by radial and ulnar collateral ligaments—cord-like structures originating from the lateral-dorsal metacarpal head and inserting into the volar proximal phalanx (proper collaterals, taut in flexion) or volar plate (accessory collaterals, taut in extension)—along with the volar plate, a fibrocartilaginous structure on the palmar aspect that prevents hyperextension and is linked to the deep transverse metacarpal ligament.^[15]^[2] A distinctive feature of the fifth metacarpal's articulations is the greater mobility of its CMC joint compared to the relatively fixed second and third CMC joints, which supports ulnar deviation and contributes to the little finger's role in cupping the palm and opposition.^[12]^[14]

Development and variations

Ossification

The ossification of the fifth metacarpal bone, like other metacarpals, follows the pattern typical of long bones through endochondral ossification, beginning with a cartilaginous precursor model that is gradually replaced by bone tissue. The primary ossification center emerges in the diaphysis (shaft) during the prenatal period, appearing around the 8th to 9th week of gestation. This center initiates the formation of the diaphysis, expanding longitudinally and radially as ossification proceeds from the mid-shaft toward the ends.^[16]^[17] Secondary ossification occurs postnatally at the distal epiphysis, specifically the head of the bone, with the center appearing between 11 and 37 months of age (typically around 1 to 2 years). Unlike the proximal phalanges or other bones with epiphyses at both ends, the fifth metacarpal lacks a separate secondary ossification center at its base; instead, proximal growth occurs via the metaphysis adjacent to the carpals. The epiphyseal center at the head undergoes endochondral ossification, where hypertrophic chondrocytes in the growth plate are replaced by osteoblasts depositing bone matrix, facilitating longitudinal expansion. Growth plates at both the base and head contribute to overall lengthening until fusion, which typically completes between 14 and 19 years of age, marking skeletal maturity.^[16]^[18]^[19] The timeline of ossification can vary due to genetic and nutritional factors, which influence the rate of chondrocyte proliferation and mineralization; for instance, malnutrition or genetic predispositions may delay the appearance of centers or prolong fusion. In certain endocrine disorders, such as hypoparathyroidism, ossification may be delayed due to impaired calcium regulation affecting bone formation. These variations highlight the role of systemic factors in modulating the standard developmental sequence.^[20]^[21]

Anatomical variations

The fifth metacarpal bone is naturally shorter than the central metacarpals, with its length typically measuring about 6 mm less than that of the fourth metacarpal on average.^[22] This inherent variation contributes to the tapered architecture of the hand's palm. Congenitally, the fifth metacarpal can exhibit further shortening in conditions such as brachydactyly type E, a hereditary disorder involving disproportionate shortening of the metacarpals and phalanges, or pseudohypoparathyroidism (also known as Albright's hereditary osteodystrophy), where shortening of the fourth and fifth metacarpals is a hallmark radiographic feature often accompanied by round facies and short stature.^[23]^[24] Clinodactyly, a condition marked by radial deviation of the little finger, is typically due to phalangeal abnormalities but can be associated with fifth ray alignment issues.^[25] In rare instances, fusion of the fourth and fifth metacarpals occurs as metacarpal synostosis, a congenital malformation that results in bony union between the two bones, often leading to a shortened and deviated fifth digit; this is typically isolated but can associate with syndromic conditions.^[26] Clinodactyly affects 1-20% of the general population and is usually benign, though its prevalence rises significantly in genetic disorders such as Down syndrome, impacting 35-79% of affected individuals.^[25]^[27] Bilateral asymmetry in fifth metacarpal length is common, with right-left differences typically ranging up to 5% and becoming more pronounced in individuals engaged in manual labor due to repetitive unilateral stress.^[28] Acquired changes, such as angulation or shortening, can arise post-traumatically from healed fractures, particularly boxer's fractures at the neck, where apex dorsal angulation and up to 3 mm of shortening may persist despite union.^[29]

Function

Muscle attachments

The fifth metacarpal bone serves as a key site for the origin of the third palmar interosseous muscle, which arises from the palmar surface of its shaft and functions to adduct the little finger toward the axis of the middle finger.^[30] Additionally, the extensor digiti minimi muscle has its tendon running along a dorsal ridge of the shaft, facilitating extension at the metacarpophalangeal joint of the little finger.^[31] Several muscles insert onto the fifth metacarpal, primarily contributing to movements of the little finger. The opponens digiti minimi originates from the hook of the hamate and the flexor retinaculum, inserting along the ulnar aspect of the base and shaft to abduct and oppose the little finger.^[32] The flexor digiti minimi brevis, arising from the hook of the hamate and flexor retinaculum, inserts on the base of the proximal phalanx of the little finger, aiding flexion at the metacarpophalangeal joint.^[33] The abductor digiti minimi, originating from the pisiform bone and the tendon of the flexor carpi ulnaris, inserts on the base of the proximal phalanx of the little finger and occasionally the fifth metacarpal base, supporting abduction at the metacarpophalangeal joint. Tendon attachments further link extrinsic muscles to the fifth metacarpal. The extensor carpi ulnaris inserts on the ulnar tubercle at the base, enabling wrist extension and ulnar deviation.^[32] Similarly, the flexor carpi ulnaris tendon attaches to the base, contributing to wrist flexion and adduction.^[32] The fourth dorsal interosseous muscle originates in part from the lateral surface of the fifth metacarpal shaft, aiding abduction of the ring finger.^[34] Collectively, the hypothenar muscles (abductor, flexor, and opponens digiti minimi) enhance grip strength on the ulnar side of the hand through these attachments.^[35] The fifth metacarpal's attachments provide essential leverage for the hypothenar eminence muscles, with a greater concentration on its ulnar side compared to other metacarpals, supporting specialized ulnar hand functions.^[36] These sites are in close proximity to branches of the dorsal metacarpal artery and the distribution of the ulnar nerve, ensuring vascular and neural support for the attached musculature.^[32]

Role in hand function

The fifth metacarpal contributes significantly to hand mobility through its carpometacarpal (CMC) joint, which permits greater excursion than the more fixed second and third metacarpals. Specifically, the fifth CMC joint allows approximately 15° of flexion/extension, 11° of abduction/adduction, and 27° of pronation/supination, enabling adaptive positioning of the little finger.^[37] This enhanced mobility facilitates palmar displacement and cupping of the palm, which is essential for conforming the hand to irregular objects during prehensile activities.^[38] In contrast to the central metacarpals, this range supports dynamic adjustments that enhance overall hand versatility. In grip mechanics, the fifth metacarpal stabilizes the ulnar border of the palm, maintaining the transverse metacarpal arch to distribute loads effectively during both power grips, such as tool handling, and precision grips, like pinching small items.^[39] The bone's alignment with adjacent metacarpals reinforces this arch, preventing collapse under compressive forces and optimizing contact with grasped objects for secure hold.^[3] The hypothenar muscles, which insert on the fifth metacarpal, utilize it as a lever to generate abduction and flexion of the little finger, supporting these grip configurations. The fifth metacarpal also enables key movements of the little finger and hand, including flexion and extension at the metacarpophalangeal (MCP) joint, ulnar deviation of the entire hand, and contributions to opposition for fine motor tasks such as writing.^[3] These actions allow the ulnar side of the hand to deviate toward the midline, promoting opposition between the thumb and little finger for precise manipulation. Biomechanically, the bone serves as a rigid lever arm for force transmission from the hypothenar muscles, while its position in the transverse arch integrates with the other metacarpals to enhance load distribution during impacts, such as in punching, where it helps absorb and redirect shock along the ulnar border. Overall, this integration bolsters hand dexterity and strength, allowing coordinated multi-finger actions essential for daily functions.^[39]

Clinical significance

Common injuries

The fifth metacarpal bone is susceptible to fractures due to its position on the ulnar side of the hand, making it vulnerable during impacts or falls. These injuries represent a significant portion of hand trauma, with metacarpal fractures accounting for 30-40% of all hand fractures.^[3]^[40] The most prevalent is the boxer's fracture, a transverse fracture at the neck of the fifth metacarpal, which comprises approximately 10% of hand fractures.^[41] This injury typically results from an axial load applied to the flexed metacarpophalangeal (MCP) joint, such as during punching a hard surface, leading to apex dorsal angulation that can be up to 70° without significant functional impairment.^[3]^[42] Shaft fractures of the fifth metacarpal often present as spiral or transverse patterns and arise from direct blows or twisting forces applied to the hand.^[43] Base fractures, in contrast, commonly occur from falls on an outstretched hand or direct ulnar border impacts, resulting in extra-articular or intra-articular disruptions at the carpometacarpal joint.^[40] These fracture types highlight the bone's exposure to both high-energy mechanisms, such as those in sports or altercations, and low-energy events like slips in the elderly.^[3] Epidemiologically, fifth metacarpal fractures peak in young males aged 10-29 years, with metacarpal fractures comprising 5-10% of all fractures overall and males affected five times more frequently than females.^[3]^[44] The annual incidence is approximately 13.6 per 100,000 person-years in the United States, with the highest rates in males aged 10-29.^[3] Complications from these injuries include malunion, which can cause rotational deformity and extensor lag, potentially leading to scissoring of the fingers or reduced grip strength.^[3] Other risks involve joint stiffness and, in open fractures from fights, infection or neurovascular compromise.^[3] The bone's structure, with its relatively narrow neck and shaft, contributes to these vulnerabilities during traumatic loading.^[40]

Diagnostic and treatment approaches

Diagnosis of disorders affecting the fifth metacarpal bone typically begins with a clinical evaluation, including assessment of pain, swelling, deformity, and hand function, followed by imaging to confirm the pathology. For suspected fractures, plain radiographs in posteroanterior, lateral, and oblique views are the primary diagnostic tool, allowing evaluation of fracture location, displacement, angulation, and rotation; the lateral view is particularly useful for measuring apex-dorsal angulation at the neck, while the Brewerton view can detect occult fractures of the metacarpal head.^[3]^[29] In cases of suspected malrotation, clinical tests such as assessing metacarpophalangeal (MCP) joint stability and finger alignment during flexion are performed to evaluate rotational deformity, which can compromise grip.^[3] For complex or intra-articular fractures where plain films are inconclusive, computed tomography (CT) provides detailed assessment of fragment alignment and joint involvement, while magnetic resonance imaging (MRI) is reserved for soft tissue or avascular changes.^[3] Non-traumatic conditions of the fifth metacarpal are less common but require targeted diagnosis. Avascular necrosis (AVN) of the metacarpal head, a rare entity often linked to repetitive stress or prior microtrauma rather than acute injury, presents with insidious pain and limited MCP motion; MRI is the most sensitive imaging modality for early detection, as initial X-rays may appear normal.^[45] Osteomyelitis, typically arising from open wounds or hematogenous spread, manifests as localized swelling, erythema, and drainage, with diagnosis confirmed by X-rays showing periosteal reaction or bone destruction, supplemented by MRI for extent of infection and blood cultures for causative organisms.^[46] Arthritis at the MCP or carpometacarpal (CMC) joints of the fifth digit, often degenerative or inflammatory, is diagnosed via clinical exam revealing stiffness and crepitus, with X-rays demonstrating joint space narrowing, osteophytes, or erosions.^[47] Treatment of fifth metacarpal fractures prioritizes restoration of alignment while minimizing stiffness, with conservative management suitable for most nondisplaced or minimally displaced cases. Closed reduction followed by immobilization in an ulnar gutter splint for 3-4 weeks is indicated for angulations less than 30-40 degrees without rotational deformity, using techniques like the 90-90 method (wrist and MCP flexed at 90 degrees) to correct apex-dorsal angulation; buddy taping to the fourth finger allows early mobilization and yields comparable functional outcomes to splinting.^[3]^[48] Surgical intervention is reserved for unstable, displaced, or open fractures, including those with greater than 40 degrees angulation, shortening over 5 mm, or malrotation; options include percutaneous Kirschner-wire (K-wire) fixation, intramedullary nailing, or open reduction internal fixation with plates, achieving stable alignment and union rates exceeding 90 percent.^[48]^[29] For non-traumatic conditions, management focuses on symptom relief and preservation of function. Avascular necrosis is initially treated conservatively with immobilization and nonsteroidal anti-inflammatory drugs (NSAIDs) to alleviate pain, with surgical curettage and bone grafting considered for progressive collapse.^[45] Osteomyelitis requires aggressive debridement of infected tissue, intravenous antibiotics tailored to culture results, and stabilization, often using the induced membrane technique for chronic cases involving bone loss, leading to infection eradication in over 80 percent of metacarpal instances.^[46] Arthritis at the fifth MCP or CMC joints is managed with NSAIDs and splinting for mild cases to reduce inflammation and improve comfort, progressing to silicone implant arthroplasty for mobility preservation in advanced MCP disease or joint fusion for severe CMC involvement when conservative measures fail.^[47] Rehabilitation emphasizes early motion to prevent stiffness, commencing 2-3 weeks post-immobilization with active range-of-motion exercises for the fingers and wrist, advancing to gentle strengthening such as ball squeezes by 4 weeks.^[3] Supervised therapy, including scar management and stretching, typically spans 6-12 weeks, achieving total active motion near 250 degrees and grip strength at 90-95 percent of baseline by 3-6 months.^[49] Outcomes show union in 90 percent of cases within 4-6 weeks for stable fractures, with full functional recovery often requiring several months.^[3] Prognosis for fifth metacarpal disorders is generally favorable with appropriate intervention, particularly for nondisplaced fractures treated conservatively, yielding excellent pain relief and return to function without formal follow-up in many cases.^[3] However, rotational deformities or untreated malalignment can lead to poor grip strength and pseudoclawing, while complications like nonunion or infection in open injuries worsen outcomes, emphasizing the need for precise initial management.^[48]

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