How to manage a patient with a fractured fifth metacarpal and significant pain?

Management of Fifth Metacarpal Fracture with Significant Pain

The patient with a fractured fifth metacarpal base requires urgent orthopedic referral, appropriate pain management with NSAIDs (ibuprofen and topical Voltaren), and temporary splinting to stabilize the fracture and improve quality of life.

Initial Assessment and Imaging

The patient presents with:

• 50-year-old male with right hand pain
• Fractured fifth metacarpal base ("shattered")
• 6/10 throbbing, constant pain
• Rotational deformity (fifth finger crosses over fourth when making a fist)
• Right-hand dominance (functional impact)

X-ray findings confirm the fracture, which appears to be at the base of the fifth metacarpal. This location is particularly concerning as base fractures:

• Are less common than neck fractures
• Often involve the carpometacarpal joint
• May require surgical intervention for optimal outcomes
• Can lead to long-term functional impairment if not properly managed

Pain Management Approach

A multimodal analgesic approach is recommended:

1. NSAIDs:

   • Continue ibuprofen as prescribed (appropriate first-line treatment)
   • Topical Voltaren cream as prescribed (provides localized pain relief)
   • These medications target inflammation and provide pain relief with minimal systemic effects 1

2. Avoid opioids if possible due to:

   • Risk of dependence
   • Side effects including sedation, constipation
   • Limited evidence for superior efficacy in this setting

3. Non-pharmacological measures:

   • Elevation of the hand above heart level
   • Application of ice (20 minutes on, 20 minutes off)
   • Temporary activity modification to avoid aggravating movements

Orthopedic Referral and Fracture Management

The presence of a rotational deformity (fifth finger crossing over fourth) is a critical finding that necessitates prompt orthopedic evaluation. This deformity:

• Indicates potential instability of the fracture
• May lead to permanent functional impairment if not corrected
• Often requires surgical intervention for optimal outcomes

Indications for Orthopedic Referral:

• Base fracture ("shattered" as described)
• Rotational deformity
• Significant pain affecting function
• Dominant hand involvement

The orthopedic specialist will determine the need for:

• Closed reduction vs. surgical intervention
• K-wire fixation, plate fixation, or other surgical techniques
• Post-reduction immobilization protocol

Temporary Management While Awaiting Orthopedic Evaluation

1. Immobilization:

   • Provide a temporary ulnar gutter splint to:
     • Stabilize the fracture
     • Reduce pain
     • Prevent further displacement
   • Position the hand in the "safe position" (wrist slight extension, MCP joints flexed 70-90°, IP joints slightly flexed)

2. Activity Modification:

   • Avoid activities that require gripping or pinching
   • Temporarily avoid weight-bearing through the hand
   • Maintain mobility of uninvolved joints to prevent stiffness

3. Follow-up:

   • Ensure orthopedic appointment is scheduled within 1 week
   • Provide clear instructions for when to return sooner (increased pain, numbness, color changes)

Common Pitfalls to Avoid

1. Underestimating the significance of rotational deformity:

   • Even small rotational malalignments can lead to significant functional impairment
   • Digital overlap during flexion must be addressed to prevent permanent disability

2. Inadequate pain management:

   • Untreated pain can lead to decreased mobility and delayed recovery
   • Multimodal approach is superior to single-agent treatment

3. Delayed orthopedic referral:

   • Base fractures often require specialized evaluation
   • Early intervention improves long-term outcomes

4. Overlooking the need for bone health assessment:

   • In patients over 50, consider whether this fracture represents a fragility fracture
   • May warrant osteoporosis evaluation in the future 1

Long-term Considerations

After acute management, the patient will likely require:

• Structured rehabilitation program
• Progressive strengthening exercises
• Gradual return to activities
• Monitoring for complications such as:
  • Malunion
  • Stiffness
  • Post-traumatic arthritis
  • Chronic pain

By following this approach, the patient has the best chance for optimal functional recovery and return to normal activities with minimal long-term impairment.