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Three Part Question

In a [young adult with a closed fracture of the fifth metacarpal neck with some angulation] is [active treatment (manipulation and/or casting) better than early mobilisation] at [reducing deformity and restoring function]?

Clinical Scenario

A 21 year old man presents on a saturday morning having been involved in a drunken brawl the night before. He has a painful swollen right (dominant) hand. An x-ray reveals a fracture of the neck of the fifth metacarpal with some angulation.

Search Strategy

Medline 1966-05/98 using the OVID interface.
({[exp metacarpus OR metacarp$] AND exp fractures} AND [fifth ti,ab,sh OR boxer ti,ab,sh OR small ti,ab,sh OR little ti,ab,sh] AND maximally sensitive RCT filter).

Search Outcome

(Not given.)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Arafa M, et al. 1986. UK.	101 patients with fifth metacarpal fractures with no rotational deformity. Early mobilisation with no dressing.	Observational.	Time until fit to work	34 within 2 weeks, 48 within 4 weeks, 19 within 12 weeks	Uncontrolled.
			Patient satisfaction	79 totally satisfied
McKerrell J, et al. 1987. Canada.	40 of 63 consecutive patients with closed fractures of the fifth metacarpal neck. Various conservative (25) vs operative management (15).	Clinical trial.	Time off work	23 (0-56) vs 58 (4-180) days	Not randomised, large variation in non-operative treatment.
			Angulation	31 vs 6 degrees
			Functional end result and grip strength	No difference
Ford DJ, et al. 1989. UK.	62 consecutive patients with fractures of the fifth metacarpal neck. No active treatment.	Observational.	Time taken for movement to recover	Full flexion at 3 weeks. Full extension at 1 year	Uncontrolled.
			Range of movement of MCPJ5	Nil at 1 year
			Time taken for pain to resolve	3 - 9 months
			Length of time off work	3 (0-12)weeks
			Presence of deformity	100% of whom 14% significant cosmetic
Maitra A and Sen B. 1990. UK.	40 patients with fractures of the fifth metacarpal neck angulated more than 30 degrees. Treated by manipulation and immobilisation.	Observational.	Angulation at 0 and 3 weeks	Significant improvement at 3 weeks but less than immediately post manipulation.	Uncontrolled. Retrospective. Short follow-up.
Konradsen L, et al. 1990. Denmark.	100 patients with metacarpal injuries of which 58 patients had subcapital fractures of the second to fifth metacarpal. Full vs functional casting.	PRCT	Angulation at cast removal	Statistically better (P<0.05) reduction in angulation for functional cast after reduction and at cast removal.	Not blind. Fractures were not reduced at all in full cast group. No unmanipulated group. Differences were not clinically relevant.
Theeuwen, et al. 1991. Netherlands.	45 of 71 patients with isolated fractures of the neck of the fifth metacarpal. Treated according to clinical decision. Closed reduction (26) vs no active treatment (19)	Clinical trial.	Shortening at 1-5 years	No difference	Not randomised. Differences were not clinically relevant.
			Angulation at 1-5 years	Statistically significant improvement (10 degrees) - P <0.05.
Breddam M and Hansen TB. 1995. Denmark.	36 of 43 patients with subcapital fractures of the fourth and fifth metacarpal neck without lateral or rotational deformity. Immediate mobilisation.	Observational.	Range of movement in the MCPJ (clinical)	Range of movement normal (compared with opposite hand) in 64%	No control group. Short follow-up period.
			Volar angulation at 4 weeks	Unchanged in 89%
			Patient satisfaction	Full satisfaction in 86%
Braakman M. 1997. Netherlands.	200 patients with primary fractures of the fourth and fifth metacarpals of which 63% were subcapital. Anatomical (< 5 degrees) reduction vs partial reduction.	Case-control.	Difference in residual angulation at follow-up at 4 weeks	No significant difference in subcapital fractures
Braakman M, et al. 1998. Netherlands.	48 of 50 patients with fractures of the fifth metacarpal of which 35 were subcapital. Ulnar gutter plaster vs adjacent strapping of fourth and fifth fingers.	PRCT	Residual symptoms at 6 months	No difference	Subcapital and shaft fractures.
			Functional recovery	Significantly different (56% vs 100%) at 4 weeks. No difference at 6 months.

Comment(s)

There is no single study that answers the question posed. The evidence available is of variable quality but all points to the conclusion that manipulation and splintage of forth and fifth metacarpal neck fractures to correct volar angulation is pointless, and that early mobilisation leads to early functional recovery with no apparent increase in residual symptoms. A well designed PRCT examining metacarpal neck fractures alone is warranted.

Clinical Bottom Line

Fractures of the fourth and fifth metacarpal necks without rotational deformity should be treated by adjacent strapping the ring and little fingers and by encouraging early mobilisation.

References

1. Arafa M, Haines J, Noble J, Carden D. Immediate mobilization of fractures of the neck of the fifth metacarpal. Injury 1986;17(4):277-278.
2. McKerrell J, Bowen V, Johnston G, Zondervan J. Boxer's fractures -- conservative or operative management? J Trauma 1987;27(5):486-490.
3. Ford DJ, Ali MS, Steel WM. Fractures of the fifth metacarpal neck: is reduction or immobilisation necessary? J Hand Surg [Br] 1989;14(2):165-167.
4. Maitra A, Sen B. Displaced boxers' fractures: a simple and effective method of external splintage. Br J Clin Pract 1990;44(9):348-351.
5. Konradsen L, Nielsen PT, Albrecht-Beste E. Functional treatment of metacarpal fractures 100 randomised cases with or without fixation. Acta Orthop Scand 1990;61(6):531-534.
6. Theeuwen GA, Lemmens JA, van Niekerk JL. Conservative treatment of boxers fracture: a retrospective analysis. Injury 1991;22(5):394-396.
7. Breddam M, Hansen TB. Subcapital fractures of the fourth and fifth metacarpals treated without splinting and reposition. Scand J Plast Reconstr Hand Surg 1995;29(3):269-270.
8. Braakman M. Is anatomical reduction of fractures of the fourth and fifth metacarpals useful? Acta Orthop Belg 1997;63(2):106-109.
9. Braakman M, Oderwald EE, Haentjens MH. Functional taping of fractures of the 5th metacarpal results in a quicker recovery. Injury 1998;29(1):5-9.