Treatment for Distal First Metacarpal Fractures
Conservative management is recommended for most isolated distal first metacarpal fractures with less than 50% involvement and stable joints, while surgical fixation is necessary for larger fragments or unstable joints. 1
Diagnostic Approach
- Initial assessment should include standard radiographs as first-line imaging
- If radiographs are equivocal but clinical suspicion remains high:
- CT without contrast is recommended to confirm fracture and distinguish from bipartite sesamoid
- MRI without contrast can evaluate associated soft tissue injuries, particularly volar plate tears 1
Treatment Algorithm
Conservative Management
For stable fractures with <50% involvement and stable joints:
- Immobilize the thumb in a thumb spica splint to maintain proper alignment
- Position the wrist in flexion and forearm in supination to counteract volar displacement of the distal fragment 1
- Duration of immobilization should be limited to prevent stiffness and complications
- NSAIDs are recommended for pain and inflammation control 1
Surgical Management
Indicated for:
- Fractures with >50% articular involvement
- Unstable joints
- Comminuted fractures
- Significant displacement
Surgical options include:
- Open reduction and internal fixation (ORIF) with micro-screws or K-wires 2
- Percutaneous pinning for less complex fractures
- External fixation for highly comminuted fractures 3
The volar approach offers excellent fracture exposure for intra-articular fractures of the first metacarpal base, allowing proper visualization and fixation placement 2.
Rehabilitation Protocol
- Early mobilization after stable surgical fixation is beneficial for optimal outcomes 1
- Implement a directed home exercise program including active motion exercises to prevent stiffness
- Limiting immobilization duration reduces complications
- Regular movement through complete range of motion is crucial for optimal outcomes 1
Special Considerations
- Diabetic patients require close monitoring of skin to prevent pressure points and breakdown
- Elderly patients should be evaluated for osteoporosis and considered for calcium/vitamin D supplementation
- Smoking increases nonunion rates and leads to inferior clinical outcomes 1
Potential Complications
- Joint stiffness
- Chronic pain
- Recurrent instability
- Post-traumatic arthritis
- Extensor lag
- Narrowing of the first web space 4
Early recognition and appropriate treatment are essential, as delayed treatment can lead to poor outcomes. Persistent symptoms warrant prompt advanced imaging rather than prolonged observation 1.