From the Guidelines
The next steps in managing this 54-year-old male with intermittent pain between the 2nd and 3rd metacarpal heads following a previous right-hand second metacarpal fracture should include a comprehensive evaluation and targeted treatment plan, starting with updated radiographs of the hand to assess fracture healing and rule out post-traumatic complications, as recommended by the most recent guidelines 1.
Initial Evaluation
The patient should undergo a detailed physical examination focusing on:
- Tenderness
- Range of motion
- Grip strength
- Neurovascular status This evaluation will help identify any potential mechanical or inflammatory causes of the patient's pain.
Pain Management
For pain management, consider starting with:
- Acetaminophen 500-1000mg every 6 hours
- NSAIDs like ibuprofen 400-600mg three times daily with food for 7-10 days, unless contraindicated 1 These medications can help alleviate pain and inflammation while further evaluation and treatment are planned.
Rehabilitation
Physical therapy should be prescribed, focusing on:
- Hand strengthening exercises
- Range of motion
- Desensitization techniques Typically, 2-3 sessions weekly for 4-6 weeks can help improve function and reduce pain. A custom-made hand splint for nighttime use may provide additional relief by supporting the hand and reducing stress on the affected area.
Further Evaluation and Treatment
If conservative measures fail after 4-6 weeks, consider referral to a hand specialist for further evaluation, which might include:
- Advanced imaging (MRI or CT scan) to assess for soft tissue injuries, neuroma formation, or subtle bony abnormalities 1
- Corticosteroid injection may be considered for persistent pain, particularly if there's evidence of inflammation This approach addresses both the mechanical aspects of post-fracture pain and the potential inflammatory components while providing symptom relief during the diagnostic process.
From the Research
Next Steps in Managing the Patient
The patient reports intermittent pain between the 2nd and 3rd metacarpal heads, which may be related to the previous fracture. To further evaluate this pain, repeating the x-ray is a good first step.
Pain Management Options
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may be considered for pain management, as they have been shown to reduce post-trauma pain and the need for opioids in patients with traumatic fractures 2.
- However, the use of NSAIDs has been associated with an increased risk of nonunion in some studies, although the evidence is not conclusive 3, 4, 5.
- Intraarticular corticosteroid injections may also be considered, as they have been shown to provide quick pain relief in patients with osteoarthritis of the hip 6.
Considerations for NSAID Use
- The patient's fracture healing process should be closely monitored if NSAIDs are prescribed, as they may impair fracture healing due to the inhibition of the endochondral ossification pathway 3.
- The timing, duration, and dose of NSAID administration should be carefully considered, as animal data suggest that these factors can affect the risk of nonunion 3, 4.
- Short-term administration of NSAIDs may be safer than long-term use, although more research is needed to confirm this 2, 5.