Ulnar Gutter Splint for Fourth Metacarpal Neck Fracture
For fourth metacarpal neck fractures, an ulnar gutter splint is the recommended standard immobilization method, providing adequate stabilization while allowing for functional recovery. 1
Initial Management and Immobilization
Assessment and Imaging
- Standard radiographs are the initial imaging of choice to confirm diagnosis and rule out associated fractures 1
- Multiple views should be obtained, including:
- Standard AP view
- Externally rotated oblique view
- Internally rotated oblique view (increases diagnostic yield) 1
- CT without IV contrast may be considered in equivocal cases to better visualize fracture morphology 1
Immobilization Technique
- Ulnar gutter splint is the standard immobilization method for fourth metacarpal neck fractures
- The splint should:
- Maintain the hand in a functional position
- Immobilize the wrist, fourth and fifth metacarpals, and corresponding digits
- Avoid excessive angulation that could compromise function 1
- Ensure the splint does not compromise circulation by overtightening 1
- Monitor for signs of complications such as malunion or stiffness 1
Duration and Follow-up
- Average immobilization duration is approximately 3-4 weeks 1
- Clinical and radiographic reassessment should be performed at 2-3 weeks to evaluate fracture healing progression 1
- Progressive range of motion exercises should begin after the immobilization period 1
- Full recovery is typically expected within 6-8 weeks 1
Rehabilitation Protocol
- Active finger motion exercises should be implemented immediately after immobilization to prevent stiffness 1
- Directed home exercise programs should be implemented after the immobilization period (3-4 weeks) 1
- Progressive strengthening exercises for intrinsic hand muscles should be incorporated in long-term rehabilitation 1
Special Considerations
Pain Management
- NSAIDs are recommended for pain and inflammation control 1
- Ice application during the first 3-5 days can provide symptomatic relief 1
Patient-Specific Factors
- For diabetic patients: Close monitoring of skin is essential to prevent pressure points and breakdown 1
- For elderly patients: Consider calcium and vitamin D supplementation 1
- For athletes: Discuss realistic timeline for return to sports activities 1
- Children: May allow for shorter immobilization periods due to faster healing rates 1
Alternative Treatment Options
While ulnar gutter splint is the standard treatment, research suggests alternative approaches may be considered in specific cases:
- Functional taping has shown earlier functional recovery compared to plaster immobilization in fifth metacarpal fractures, which may be applicable to fourth metacarpal fractures as well 2
- For patients requiring faster return to work (e.g., office workers with high expectations), surgical fixation techniques may be considered 3, 4
Potential Complications and Monitoring
- Monitor for signs of compromised circulation (blue, purple, or pale extremity) 1
- Watch for malunion or stiffness 1
- Evaluate for symptoms in ulnar nerve distribution, including sensory deficits in the 4th and 5th digits 1
Important Caveats
- Avoid excessive angulation that could compromise function 1
- Rotary deformity or ulnar angulation at the fracture site can lead to more serious sequelae than volar angulation 5
- Low-intensity pulsed ultrasonography (LIPUS) should NOT be used as it does not accelerate healing or lower rates of nonunion 1
- Patient education on proper immobilization device use and care is crucial for optimal recovery 1