Management of Spiral Fracture of the 5th Metacarpal with 40 Degree Volar Displacement
Surgical intervention with closed reduction and percutaneous pinning is recommended for a spiral fracture of the 5th metacarpal with 40 degree volar displacement, as this exceeds the 30-degree threshold for conservative management. 1, 2
Assessment and Imaging
- Initial evaluation should include standard radiographic examination with at least 3 views (posteroanterior, lateral, and 45° semipronated oblique) 1
- An internally rotated oblique projection may increase diagnostic yield for metacarpal fractures 1
- CT imaging is typically not indicated unless there is concern for complex articular involvement 1, 3
Treatment Algorithm
Indications for Surgical Management
- Volar displacement >30 degrees (patient has 40 degrees) 4, 2
- Presence of any rotational deformity 2, 5
- Open fractures 4
- Significant shortening (>5mm) 4
Recommended Surgical Approach
- Closed reduction with percutaneous Kirschner wire (K-wire) fixation under image intensifier guidance is the preferred technique 6, 2
- Intramedullary K-wire nailing is considered the reference technique for displaced fractures of the fifth metacarpal 7
- Open reduction may be necessary in cases with comminution or when closed restoration of the articular surface is not feasible 6
Conservative Management (Not Appropriate for This Case)
- Reserved for fractures with angulation <30 degrees without rotational deformity 4, 2, 5
- When used, typically involves buddy strapping with a Futura splint 2
Post-Operative Management
- Active finger motion exercises should be initiated immediately following diagnosis and treatment to prevent stiffness 3
- Wrist motion does not need to be started early following stable fracture fixation 3
- When external fixation is used, limiting the duration of fixation is recommended to reduce complications 3
- Consider vitamin C supplementation for prevention of disproportionate pain 3
Potential Complications to Monitor
- Finger stiffness (most common functionally disabling complication) 3
- K-wire migration 7
- Neurologic lesions 7
- Delayed consolidation 7
- Malrotation leading to finger overlap 2
- Reduced grip strength 5
Prognosis
- With appropriate surgical management, good functional outcomes can be expected 6, 2
- Intramedullary K-wire fixation typically provides better mobility outcomes compared to plate fixation, with mean relative metacarpophalangeal flexion of 98% of healthy-side values 7
- Proper management is crucial for rehabilitation and early return to work 2