Treatment of Spiral Fracture of the Fifth Metacarpal
For spiral fractures of the fifth metacarpal, functional taping is recommended over cast immobilization as it leads to quicker functional recovery while achieving similar long-term outcomes. 1
Initial Assessment and Imaging
- Standard radiographic examination should include at least 3 views (posteroanterior, lateral, and 45° semipronated oblique) to properly visualize metacarpal fractures 2
- An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for metacarpal fractures 2
- CT imaging is usually not indicated for metacarpal fractures during acute injury unless there is concern for complex articular involvement 2
Treatment Algorithm
Conservative Management (First-Line for Most Cases)
Functional taping is superior to cast immobilization for fifth metacarpal fractures, allowing for:
- Earlier functional recovery
- Similar long-term anatomical and functional outcomes
- Fewer residual symptoms at 6 months 1
For spiral/long oblique fractures specifically:
- A palmar wrist splint with immediate mobilization of finger joints is effective
- This approach allows for fracture union while preventing extension lag and preserving grip strength (reaching 94% of contralateral hand strength by 1 year) 3
Indications for Surgical Management
Surgical fixation should be considered for:
- Unstable fractures with significant displacement
- Intra-articular fractures with articular surface disruption
- Fractures with rotational deformity that cannot be corrected with closed methods 4
Surgical Options When Indicated
- Closed reduction with percutaneous pinning using Kirschner wires under image intensifier guidance
- Open reduction with multiple Kirschner wire fixation for:
- Comminuted fractures
- Cases where closed restoration of articular surface is not feasible 4
Follow-up and Expected Outcomes
- Extension lag may be initially present but typically resolves with appropriate treatment and rehabilitation 3
- Grip strength progressively improves, reaching near-normal levels within one year 3
- Fracture angulation may change during healing, particularly in fractures that required reduction, regardless of immobilization method 1
Common Pitfalls and Considerations
- Inadequate reduction of fifth metacarpal base fractures may result in pain, functional disability, and osteoarthritic changes 4
- Despite the common occurrence of metacarpal fractures (18-44% of all hand fractures), there remains controversy regarding optimal treatment algorithms 5
- The fifth finger is the most commonly involved in metacarpal fractures, accounting for the highest percentage of non-thumb metacarpal injuries 5
- A Cochrane review found no statistically significant difference between various non-operative treatment modalities, suggesting that functional approaches are at least as effective as rigid immobilization 6