Fractures of the Fourth Metacarpal

Abstract

In the absence of unreducible rotational malalignment, fourth metacarpal fractures may be adequately treated nonoperatively with a protocol of casting and outrigger.

Long-term follow-up of unoperated, nonscissoring spiral metacarpal fractures

“…Because this shortening can theoretically lead to a decrease in power, a surgical approach has often been used in the management of these fractures to preserve metacarpal length (16). With the wide variety of open and closed surgical techniques and their effectiveness in restoring metacarpal length, surgeons tend to have a reduced threshold for selecting operative fixation of these fractures due to their fear of metacarpal shortening and its effects on power (13,16,33). Closed surgical reduction is less effective at restoring length than open techniques and, therefore, open reduction and internal fixation (ORIF) has tended to be the operative approach of choice (5).…”

“…There is considerable variability throughout the literature regarding the maximum amount of shortening that results from metacarpal fracture and the acceptable limits of such shortening (1,9,12,(14)(15)(16)(17)(18)(19)(20)(21)31). Published guidelines regarding the degree of metacarpal shortening that is consistent with good hand function range throughout the literature from 2 mm to 10 mm (9).…”

“…Spiral metacarpal fractures commonly result in some shortening of the metacarpal shaft (9), which may subsequently cause extension lag at the metacarpophalangeal (MCP) joint and reduced grip strength (9-13). Several studies have documented the relationship between shortening and hand function (1,9,12,(14)(15)(16)(17)(18)(19)(20)(21), although the maximum amount of shortening that occurs following metacarpal fracture and acceptable limits appear to be controversial.Historically, spiral fractures occurring without scissoring have been treated surgically to restore metacarpal length and prevent these losses in power and function. Although previous studies have demonstrated beneficial outcomes in hand function following operative treatment of spiral metacarpal fractures (5,18,(22)(23)(24)(25)(26)(27)(28), surgical management is not without consequences and complications (27-31).…”

“…Stripping of the interossei, which power MCP flexion from the underlying bone for internal fixation, for example, may also lead to power loss. Furthermore, one must consider the cost, complications and consequences associated with surgery, postoperative management and wound healing.Increasingly, conservative management of nonscissoring spiral metacarpal fractures has come into favour in the absence of absolute indications for a surgical approach (10,11,16,32). Despite potential shortening of the metacarpal, a nonoperative approach preserves the integrity of the intrinsic muscles of the hand, thereby benefiting functional recovery, while also avoiding the aforementioned consequences and costs of surgery.…”

“…Spiral metacarpal fractures commonly result in some shortening of the metacarpal shaft (9), which may subsequently cause extension lag at the metacarpophalangeal (MCP) joint and reduced grip strength (9-13). Several studies have documented the relationship between shortening and hand function (1,9,12,(14)(15)(16)(17)(18)(19)(20)(21), although the maximum amount of shortening that occurs following metacarpal fracture and acceptable limits appear to be controversial.…”