Objectives <p>Metacarpal fractures are common injuries that are frequently managed with repeated radiological follow-up, although the clinical value of routine imaging is uncertain. The aim of this study was to evaluate the frequency and clinical impact of follow-up imaging in patients with metacarpal fractures treated operatively or non-operatively, and to quantify the associated financial and environmental impact.</p> Materials and methods <p>This retrospective study evaluated adult patients with metacarpal fractures treated non-operatively or operatively at a Dutch level 2 trauma center between 2017 and 2022. Radiology reports and medical records were reviewed to assess whether follow-up imaging led to treatment modification. Additionally, the corresponding financial and environmental impact was calculated.</p> Results <p>A total of 2342 patients were included (median age 32&#xa0;years; 28% female). Among initially non-operatively treated patients (<i>n</i> = 1978), 1.1% (<i>n</i> = 22) required conversion to surgery. The overall cost associated with this 1% conversion amounted to €230,000, with an estimated environmental impact of 2711&#xa0;kg CO₂-eq. Among operatively treated patients (<i>n</i> = 386), postoperative imaging rarely prompted re-operation (0.3%, <i>n</i> = 1). The total costs associated with 0.3% re-operation were €171,000 and an associated environmental impact of 1801&#xa0;kg CO₂-eq. Together, the impact equals almost one trip around the world by car.</p> Conclusions <p>Routine radiological follow-up after the initial decision for operative or non-operative treatment in metacarpal fractures provided minimal clinical benefit. A symptom-driven approach may optimize care while reducing unnecessary financial and environmental burden.</p> <p>Level of evidence: Level IV</p>