What is the recommended treatment for a comminuted proximal metacarpal fracture?

Treatment of Comminuted Proximal Metacarpal Fractures

Comminuted proximal metacarpal fractures should be treated with plate fixation as the primary surgical approach, as this provides the most stable construct for these complex fracture patterns. 1

Initial Assessment and Treatment Decision

The decision between conservative and surgical management depends on specific fracture characteristics:

• Surgical treatment is indicated when there is palmar angulation >20-30 degrees, shortening >5 mm, or rotational deformity, as these significantly impair hand extension and flexion 1, 2
• Inherently stable fractures without displacement can be managed conservatively with immobilization 1
• The degree of comminution at the proximal metacarpal base creates instability that typically requires surgical stabilization to prevent late degenerative changes 3

Surgical Treatment Options

Primary Recommendation: Plate Fixation

Plate fixation is the preferred method for comminuted metacarpal fractures because it provides rigid stability and allows early mobilization 1. This technique:

• Offers superior stability compared to other fixation methods for comminuted patterns
• Allows anatomic reduction of multiple fragments
• Enables early range of motion rehabilitation

Alternative: External Fixation with Ligamentotaxis

For severely comminuted fractures where direct fixation is not feasible, external fixation in distraction mode is an effective alternative 3, 4, 5:

• Apply external fixator spanning from the radius to the affected metacarpal (or to an adjacent stable metacarpal)
• Maintain distraction for 6 weeks to allow ligamentotaxis to restore carpal/metacarpal height and alignment 3
• Add transmetacarpal K-wire fixation from the affected to an adjacent metacarpal for additional rotational stability 5
• This technique is particularly useful when comminution prevents adequate screw or plate purchase 4

Less Preferred: Intramedullary K-wire Fixation

Intramedullary K-wire fixation is NOT recommended for comminuted proximal metacarpal fractures 1, 2. While this technique works well for simple transverse or short oblique fractures, it provides insufficient stability for comminuted patterns where multiple fragments require control.

Surgical Timing and Technique Considerations

• Perform surgery after soft tissue swelling subsides but before significant fracture healing begins (typically within 7-14 days)
• For plate fixation, use low-profile implants to minimize soft tissue irritation
• When using external fixation, average operative time is approximately 25-30 minutes 5
• Closed fractures typically unite within 6-8 weeks 5

Common Pitfalls to Avoid

• Do not use simple K-wire fixation alone for comminuted fractures, as this provides inadequate stability and risks malunion 1
• Avoid conservative treatment when carpal height index is compromised by comminution, as this leads to late degenerative changes 3
• Do not accept residual rotational deformity, as even 10 degrees of rotation significantly affects hand function 2
• Be aware that open fractures (such as from gunshot injuries) may develop reflex sympathetic dystrophy and require longer healing time (up to 8 weeks) 5

Postoperative Management

• Remove external fixators at 6 weeks and begin immediate mobilization 3
• For plate fixation, begin protected range of motion exercises within 2-3 weeks
• Expect full restoration of metacarpal joint function in uncomplicated cases 2
• Monitor for extension deficits and rotational deformities during follow-up 2