What is the appropriate management for a 54-year-old male patient with an avulsion injury involving the head of the second metacarpal, currently experiencing mild pain (3/10) and wearing a half cast, six days post-injury, with a plan for a fiberglass cast, naproxen (Naproxen) 500 mg twice daily as needed, and follow-up in six weeks?

From the Guidelines

The patient should continue with the current treatment plan, wearing the fiberglass cast for 6 weeks, taking naproxen 500 mg twice daily as needed, and returning for cast removal and follow-up x-rays in 6 weeks. The current pain level of 3/10 indicates improvement, which is encouraging. The fiberglass cast provides better immobilization than the temporary half cast, which is essential for proper healing of avulsion injuries where bone fragments have been pulled away from the main bone by tendon or ligament forces. Six weeks is the standard healing time needed for metacarpal injuries to achieve adequate bone union. According to the American College of Radiology 1, MRI may be useful in evaluating tendon injuries and helping with surgical planning, but in this case, the patient's improvement and the current treatment plan do not necessitate further imaging at this time. The patient should keep the cast dry, monitor for increased pain, swelling, or numbness, and seek immediate attention if these symptoms develop. Additionally, the use of naproxen 500 mg twice daily as needed is supported by the American College of Rheumatology 2, which recommends the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management in patients with osteoarthritis, and by extension, for pain management in patients with acute hand and wrist trauma.

Some key points to consider in the patient's care include:

• Monitoring for signs of complications, such as increased pain, swelling, or numbness
• Keeping the cast dry to prevent infection and promote healing
• Returning for follow-up x-rays in 6 weeks to assess healing and remove the cast
• Continuing to take naproxen 500 mg twice daily as needed for pain management
• Seeking immediate attention if symptoms worsen or if the patient experiences any concerns.

It is essential to prioritize the patient's morbidity, mortality, and quality of life in the treatment plan, and the current approach appears to be appropriate based on the available evidence 1, 2.

From the FDA Drug Label

Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals A lower dose should be considered in patients with renal or hepatic impairment or in elderly patients The recommended dose is 250 mg, 375 mg, or 500 mg twice daily The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required.

The patient is a 54-year-old male, and naproxen 500 mg BIDPRN is prescribed.

• The dose is within the recommended range for the patient's condition.
• However, considering the patient's age, caution is advised when high doses are required, and some adjustment of dosage may be required in elderly patients.
• Given the patient's current condition and the fact that they are reporting less pain, the prescribed dose of naproxen 500 mg BIDPRN seems reasonable, but it is essential to monitor the patient's response and adjust the dosage as needed 3.

From the Research

Treatment of Metacarpal Fractures

• The patient's treatment plan involves immobilization in a fiberglass cast for 6 weeks, which is consistent with the treatment approach outlined in 4, where patients with metacarpal fractures were immobilized for 4-5 weeks.
• The use of a fiberglass cast allows for maintenance of wrist and forearm function during the period of immobilization, which is an advantage of this treatment method, as noted in 4.
• The patient's reported pain level of 3/10 at the time of the visit suggests that the current treatment plan is effective in managing pain, and the renewal of naproxen 500 mg BIDPRN will continue to provide pain relief.

Avulsion Injuries

• The patient's avulsion injury involving the head of the second metacarpal is a specific type of fracture that requires careful management, as noted in 5, which reports on three cases of avulsion fractures of the base of the index metacarpal.
• The treatment approach for avulsion fractures may involve conservative management, as seen in 5, or immobilization in a cast, as in the patient's current treatment plan.

Immobilization and Rehabilitation

• The duration of immobilization for metacarpal fractures can vary, but 4-6 weeks is a common range, as seen in 4 and 6.
• The use of buddy taping, as described in 6, is an alternative method of immobilization that allows for immediate active protected mobilization, but this approach may not be suitable for all types of metacarpal fractures.
• Rehabilitation therapies, such as physical therapy, may be ordered by the surgeon to promote recovery and regain strength and range of motion, as noted in 7.