Treatment of Comminuted Fracture of the Proximal Metaphysis of the 5th Metacarpal
For a comminuted fracture of the proximal metaphysis of the 5th metacarpal bone, open reduction with multiple Kirschner wire pinning is the treatment of choice, as closed reduction is typically unsuccessful in restoring the articular surface in comminuted patterns. 1
Surgical Indication and Approach
Comminuted fractures of the proximal 5th metacarpal require surgical stabilization because these fractures are inherently unstable and inadequate reduction results in pain, functional disability, and osteoarthritic changes. 1
The proximal metaphyseal location with comminution makes closed reduction unfeasible for restoring the articular surface, necessitating open reduction. 1
Recommended Surgical Technique
Open reduction with multiple Kirschner wire fixation is the preferred method for comminuted proximal metacarpal fractures:
Perform open reduction to directly visualize and restore the articular surface under direct vision. 1
Use multiple Kirschner wires for stabilization of the comminuted fragments. 1
Image intensifier guidance should be utilized during the procedure to confirm adequate reduction and pin placement. 1
Alternative Consideration: Plate Fixation
Plate fixation is an alternative option for comminuted metacarpal fractures, particularly when the fracture pattern allows for stable screw purchase. 2
This provides more rigid fixation compared to K-wires but requires more extensive soft tissue dissection. 2
Critical Technical Points
Restoration of the articular surface is mandatory to prevent post-traumatic arthritis and functional impairment. 1
The goal is anatomic reduction with restoration of metacarpal length and alignment to prevent malrotation. 3
Malrotation must be avoided, as even minor rotational deformities cause significant functional problems with finger overlap during flexion. 3
Postoperative Management
Early functional treatment should be initiated once soft tissue swelling resolves and fracture stability is confirmed. 3
All patients treated with this approach demonstrate good functional outcomes with no arthritic changes on follow-up. 1
Common Pitfalls to Avoid
Do not attempt prolonged conservative management or closed reduction alone for comminuted proximal 5th metacarpal fractures, as displacement over 30 degrees and comminution make closed methods unsuccessful. 3
Avoid accepting articular step-off or gap, as this leads to predictable post-traumatic arthritis. 1
Do not use cast immobilization for extended periods, as this leads to stiffness without addressing the underlying instability. 1