Management of Fourth Metacarpal Fracture with Existing Distal Radius ORIF
The oblique mildly displaced and angulated fourth metacarpal fracture requires surgical fixation given the displacement and angulation, while the corticated ulnar styloid fragment requires no intervention as it does not affect outcomes. 1, 2
Fourth Metacarpal Fracture Management
Surgical fixation is indicated for this displaced and angulated metacarpal shaft fracture to restore hand function and prevent long-term complications. 1
- The presence of displacement and angulation in an oblique metacarpal shaft fracture creates biomechanical instability that will not adequately heal with conservative management alone 1
- Operative fixation should achieve <2 mm of residual articular surface step-off to avoid long-term complications such as osteoarthritis 1
- Standard surgical options include open reduction and internal fixation with plates and screws or intramedullary fixation, depending on fracture pattern 3
Ulnar Styloid Fragment Management
The small corticated ulnar styloid fragment requires no surgical intervention. 2, 4
- Ulnar styloid fractures or their nonunion do not affect the outcome of an adequately fixed distal radius fracture 2
- Recent studies demonstrate that neither the initial displacement nor the size of a concomitant ulnar styloid fracture affects clinical outcome when the distal radius is treated with volar locking plates 4
- More than half of distal radius fractures are combined with ulnar styloid fractures, and considerable cases result in nonunion without causing wrist problems 4
- Operative treatment should be avoided until better scientific evidence for treatment of pain associated with these fractures is available 2
Distal Radius ORIF Follow-up
All patients with distal radius fractures and unremitting pain during follow-up must be reevaluated to identify potential complications. 5
- Persistent pain may indicate nerve compression, DRUJ instability, or other complications requiring intervention 5
- A postreduction true lateral radiograph of the carpus should be obtained to assess DRUJ alignment 1
Rehabilitation Protocol
Immediate active finger motion exercises are mandatory to prevent the most functionally disabling complication of hand stiffness. 1
- Finger stiffness results from pain, swelling, cast obstruction, and patient apprehension, and is extremely difficult to treat after fracture healing 1
- Finger motion does not adversely affect adequately stabilized distal radius fractures regarding reduction or healing 1
- A home exercise program is an appropriate option for patients prescribed therapy after distal radius fracture 1
- Early wrist motion is not routinely necessary following stable fracture fixation 1
Critical Pitfall
The primary risk is failing to address the metacarpal fracture surgically while unnecessarily operating on the benign ulnar styloid fragment. The metacarpal displacement and angulation will lead to malunion, rotational deformity, and impaired hand function if left untreated conservatively. 1