From the Guidelines
For a proximal metacarpal fracture in an adult, I strongly recommend simple immobilization with a cast when fracture fragments are small, nonarticular, or minimally displaced. This approach is supported by the American College of Foot and Ankle Surgeons, as stated in their 2002 guidelines published in the American Family Physician 1. The immobilization cast should be applied carefully to avoid complications and ensure proper healing.
Key Considerations for Immobilization
- The cast should extend from just below the elbow to the distal palmar crease, incorporating the affected digits while leaving the thumb free to maintain hand function.
- The wrist should be positioned in slight extension, and the metacarpophalangeal (MCP) joints at 70-90 degrees of flexion to prevent stiffness.
- The cast should be applied for an appropriate duration, typically 3-4 weeks for stable, non-displaced fractures, followed by protected mobilization.
- Proper padding over bony prominences is crucial to prevent pressure sores, and the patient should be instructed to elevate the hand above heart level for the first 48-72 hours to minimize swelling.
Follow-Up and Rehabilitation
- Regular follow-up at 1-2 weeks is necessary to check for cast problems and to confirm proper fracture alignment with radiographs.
- After cast removal, protected mobilization with a removable splint for an additional 1-2 weeks can help in regaining hand function and preventing stiffness.
- Patient education on moving uninvolved digits regularly to prevent stiffness is also important, as noted in general principles of fracture management 1.
From the Research
Immobilization Options for Proximal Metacarpal Fractures
- A modified thumb spica cast (MTSC) can be used for immobilization of proximal metacarpal fractures, as seen in a study from 2, which showed successful treatment of various thumb metacarpophalangeal joint injuries, including a metacarpal fracture.
- The MTSC allows for full flexion and extension of the wrist, improving functional capabilities during immobilization, and has been shown to have good patient acceptance with no period of limited wrist motion or atrophy of forearm musculature 2.
- For non-thumb metacarpal fractures, nonoperative management of stable fractures is often preferred, with surgical techniques available for treatment of acute fractures and complications 3.
- Intra-articular fractures of the second through fifth metacarpal bases may require open reduction with internal fixation to ensure the integrity of the tendinous insertions 4.
Considerations for Casting and Orthosis Management
- Removable orthoses can be considered an equal or superior treatment method to cast immobilization for many common upper-extremity injuries, including metacarpal fractures 5.
- Immobilization recommendations for nonsurgical metacarpal fractures include a removable orthosis 5.
- The choice of immobilization method may depend on the specific injury pattern, patient function, and surgeon preference 6.