What is the recommended treatment for a 3rd and 4th mid shaft metacarpal fracture?

Management of 3rd and 4th Mid Shaft Metacarpal Fractures

A hand-based functional splint is the recommended treatment for 3rd and 4th mid shaft metacarpal fractures, allowing for excellent maintenance of fracture reduction while preserving functional motion throughout treatment. 1

Diagnostic Evaluation

• Initial assessment should include radiographs of the affected area to evaluate:

  • Size and displacement of fracture fragments
  • Presence of associated injuries
  • Evidence of joint instability 2

• For equivocal cases, CT without IV contrast may be used to:

  • Better visualize fracture morphology
  • Determine fragment size and displacement
  • Identify associated occult fractures 3

Treatment Algorithm

Non-operative Management (First-line for most cases)

1. Immobilization with Hand-Based Functional Splint:

   • Allows metacarpophalangeal joint, interphalangeal joint, and radiocarpal joint motion
   • Average splint duration: 24 days 1
   • Provides excellent maintenance of fracture reduction while preserving functional motion

2. Early Mobilization Protocol:

   • Active finger motion exercises should begin immediately following diagnosis to prevent stiffness 2
   • Progressive range of motion exercises after immobilization period

3. Pain Management:

   • NSAIDs for pain and inflammation control
   • Ice application during first 3-5 days for symptomatic relief 2
   • Oral analgesics for residual pain

Indications for Surgical Management

Surgery should be considered for metacarpal fractures that are:

• Multiple
• Unstable
• Significantly displaced or rotated
• Open fractures
• Associated with tendon injuries 4

Fractures occurring proximal to 70% of metacarpal length are more likely to require surgical intervention due to increased instability 5

Surgical Options

When surgical intervention is indicated, options include:

• A.O. mini-fragment screws and plate fixation, which allows for early mobilization (mean 7 days post-op) 4
• Other fixation methods based on injury pattern and surgeon preference 6

Rehabilitation Protocol

1. Early Phase (During Splinting):

   • Maintain active motion of uninvolved joints
   • Begin directed home exercise program 2

2. Post-Immobilization Phase:

   • Progressive range of motion exercises
   • Gradual return to activities 2

Complications to Monitor

• Joint stiffness
• Muscle atrophy
• Chronic pain
• Complex regional pain syndrome (more common with excessive immobilization) 2

Special Considerations

• Most patients with hand-based functional splinting can continue working without missing days (20 out of 24 in one study) 1
• Avoid excessive immobilization to prevent complications
• Children have higher tolerance for immobilization and faster healing rates 2

Prognosis

With appropriate treatment, metacarpal fractures typically have excellent outcomes:

• Consistent union without infection or deformity
• Return to work in approximately 6 weeks for manual laborers 4
• Most patients regain full movement or functional range of motion 1, 4

The primary treatment goals are to achieve anatomic and stable reduction, bony union, and early mobilization to minimize disability and optimize functional outcomes 7.