Management of fractures of the neck of the fifth metacarpal
Date First Published:
March 1, 2000
Last Updated:
May 16, 2001
Report by:
Kevin Mackway-Jones, Consultant (Manchester Royal Infirmary)
Search checked by:
Simon Carley, Manchester Royal Infirmary
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.
Search Details:
({[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).
Outcome:
(Not given.)
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Immediate mobilization of fractures of the neck of the fifth metacarpal. Arafa M, Haines J, Noble J, Carden D. 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 | ||||
| Boxer's fractures -- conservative or operative management? McKerrell J, Bowen V, Johnston G, Zondervan J. 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 | ||||
| Fractures of the fifth metacarpal neck: is reduction or immobilisation necessary? Ford DJ, Ali MS, Steel WM. 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 | ||||
| Displaced boxers' fractures: a simple and effective method of external splintage. Maitra A, 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. |
| Functional treatment of metacarpal fractures 100 randomised cases with or without fixation. Konradsen L, Nielsen PT, Albrecht-Beste E. 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. |
| Conservative treatment of boxers fracture: a retrospective analysis. Theeuwen GA, Lemmens JA, van Niekerk JL. 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. | ||||
| Subcapital fractures of the fourth and fifth metacarpals treated without splinting and reposition. Breddam M, 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% | ||||
| Is anatomical reduction of fractures of the fourth and fifth metacarpals useful? 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 | |
| Functional taping of fractures of the 5th metacarpal results in a quicker recovery. Braakman M, Oderwald EE, Haentjens MH. 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. |
Author Commentary:
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.
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:
- Arafa M, Haines J, Noble J, Carden D.. Immediate mobilization of fractures of the neck of the fifth metacarpal.
- McKerrell J, Bowen V, Johnston G, Zondervan J.. Boxer's fractures -- conservative or operative management?
- Ford DJ, Ali MS, Steel WM.. Fractures of the fifth metacarpal neck: is reduction or immobilisation necessary?
- Maitra A, Sen B.. Displaced boxers' fractures: a simple and effective method of external splintage.
- Konradsen L, Nielsen PT, Albrecht-Beste E.. Functional treatment of metacarpal fractures 100 randomised cases with or without fixation.
- Theeuwen GA, Lemmens JA, van Niekerk JL.. Conservative treatment of boxers fracture: a retrospective analysis.
- Breddam M, Hansen TB.. Subcapital fractures of the fourth and fifth metacarpals treated without splinting and reposition.
- Braakman M.. Is anatomical reduction of fractures of the fourth and fifth metacarpals useful?
- Braakman M, Oderwald EE, Haentjens MH.. Functional taping of fractures of the 5th metacarpal results in a quicker recovery.