Challenging the dogma: severely angulated neck fractures of the fifth metacarpal must be treated surgically

Abstract

Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the validity of these threshold values. Eighteen prospective comparative studies on operative and/or conservative treatment options in adults were included. None of the studies demonstrated any correlation between the residual or initial angulation and the clinical results despite accepting more severe angular deformities. Closed reduction and immobilization without internal fixation improved the palmar angle by 5° to 9° in three studies and 29° in a fourth. Operative treatments compared with non-reducing conservative treatments showed no benefit of the surgery other than aesthetic issues. The synthesis of this review indicates that 90% of fractures of the metacarpal neck with apex angulation up to 70° can be treated successfully with a functional metacarpal brace without reduction. Disability of the Arm, Shoulder and Hand questionnaire scores <10 are uniformly reported. I modified my own practice accordingly a decade ago to treating these fractures conservatively regardless of the palmar angulation, except in patients with exceptional demands or other fracture deformities.

Die konservative Behandlung von Mittelhand- und Fingerfrakturen

“…Der erste lag in der Verlagerung des Beobachterstandortes: weg vom Therapeuten und hin zum Patienten. Der zweite war die Priorisierung der Funktion vor abstrakten Messwerten oder gar Röntgenbildern [1,2]. Dabei halfen Studien, die mit allzu lange gepflegten Dogmen aufräumten.…”

Metacarpal fractures

“…However, osteotomy and fixation may be required if function is impaired (Khan and Giddins, 2015). Ultimately, the least invasive method is preferred as open reduction increases the risk of soft tissue scarring and MCP joint stiffness (Boeckstyns, 2021). ‘Bouquet pinning’ was initially described by Foucher in 1995 as a method of ‘closed’ osteosynthesis that allowed early mobilization (Foucher, 1995) (Figure 2).…”

What’s New in Hand and Wrist Surgery

“…Furthermore, osseous mallet injuries treated with a surgical procedure have a high major complication rate 63 . Angulated fifth metacarpal neck fractures treated nonoperatively are known to have good outcomes regardless of residual angulation 64 . A report of 72 patients randomized to buddy taping or closed reduction and cast immobilization demonstrated that patients with a fifth metacarpal neck fracture treated with buddy taping returned to work 28 days sooner and had fewer complications, similar functional scores, and similar residual angulation compared with those treated with casting 65 .…”