What is the appropriate management for a 26-year-old male patient with a significantly displaced, subacute, right fourth metacarpal fracture, presenting with limited movement, pain, and decreased grasping, and having a 0.72 cm shortening and 2 mm cortical separation, diagnosed by Orthopedic (OP) consultation at the prison's Outpatient Clinic (OPC)?

From the Guidelines

I strongly recommend orthopedic consultation for surgical evaluation of this patient's right fourth metacarpal fracture. The X-ray shows an oblique, subacute fracture with 2mm cortical separation and approximately 0.72cm of shortening, which indicates significant displacement and potential for poor healing. The patient's symptoms of limited movement, pain, and decreased grasping ability one month after injury, despite casting, suggest that conservative management may not be sufficient 1.

Key Considerations

• The patient's fracture shows significant shortening, which can lead to decreased grip strength and chronic pain if not properly addressed.
• The presence of a subacute fracture with cortical separation and limited movement in the affected digit indicates a high risk of poor healing and functional impairment.
• Early surgical intervention is crucial to restore proper alignment and length of the metacarpal, and to prevent long-term complications such as permanent deformity and decreased grip strength.

Management

• The patient should continue immobilization and receive appropriate pain management to prevent further injury and alleviate symptoms.
• Orthopedic consultation should be prioritized to evaluate the need for surgical intervention, which may involve open reduction and internal fixation.
• The patient should avoid activities that could worsen the injury, and follow a rehabilitation plan to restore function and mobility in the affected hand. While the study by 1 provides guidance on the treatment of distal radius fractures, the more recent study by 1 provides relevant information on the management of acute hand and wrist trauma, including the importance of early surgical intervention for significantly displaced fractures.

From the Research

Fracture Assessment and Treatment

• The patient's x-ray report indicates a subacute fracture through the distal fourth metacarpal without complete bone union, with cortical separation by about 2 mm 2.
• The patient has limited movement in his left fourth digit and reports pain and decreased grasping, which may be related to the significantly displaced right fourth metacarpal fracture 3.
• The displacement of the fracture shortens approximately 0.72 cm, which may affect the patient's functional outcomes and require consideration in treatment planning 4.

Bone Union and Healing

• The process of bone union is complex and involves various physiological processes, including osteogenetic processes, mineralization of bone tissue, and bone rotation 3.
• The role of angiogenesis in fracture healing is important, and hormonal and physical factors can affect the course and stimulation of bone union 3.
• Methods such as electrical, electromagnetic, and ultra-sound stimulation may be used to support and stimulate the bone union process 3.

Treatment Options

• The treatment of fractures depends on various factors, including the patient's age, functional demands, and individual risk profile 2.
• For displaced fractures, treatment options may include internal fixation or arthroplasty, and the choice of treatment depends on the patient's specific condition and needs 2, 4.
• Earlier operative intervention for fractures may improve the probability of achieving an anatomic reduction and better functional outcomes 5.

Assessment of Fracture Healing

• The assessment of fracture union is critical in clinical orthopaedics, but there is no established "gold standard" for fracture healing 6.
• Orthopaedic surgeons may rely on a range of tools, including radiographic assessment, mechanical assessment, serologic markers, and clinical evaluation, to determine fracture union 6.
• A composite outcome measure consisting of radiographic and functional assessments may be used to increase the quality and consistency of fracture healing trials 6.