What is the treatment for a 5th metacarpal fracture in a child?

Treatment of 5th Metacarpal Fracture in a 6-Year-Old

For a 5th metacarpal fracture in a 6-year-old child, conservative treatment with immobilization (either a hand-based splint or ulnar gutter cast) is the recommended approach, as pediatric metacarpal fractures have excellent remodeling potential and most heal successfully without surgery. 1, 2

Initial Assessment and Management

Key Clinical Evaluation Points

• Assess for rotational deformity by examining finger cascade when the child makes a fist - all fingers should point toward the scaphoid tubercle 2
• Check neurovascular status carefully, documenting sensation and perfusion in all digits 1
• Obtain radiographs to determine fracture location (neck, shaft, or base), displacement, and angulation 2
• Evaluate for open fracture or skin compromise, which would require urgent surgical washout 1

Acceptable Angulation in Pediatric Patients

During the COVID-19 pandemic guidelines, pediatric orthopedic experts emphasized accepting more initial deformity than previously tolerated in children due to their high remodeling potential. 1 This principle applies broadly to pediatric metacarpal fractures - children aged 6 years have substantial remaining growth and excellent capacity for remodeling of angular deformity over 6-12 months.

Treatment Algorithm

For Non-Displaced or Minimally Displaced Fractures

• Apply a hand-based functional splint or ulnar gutter cast for 3-4 weeks 3, 2
• Hand-based splints allow metacarpophalangeal, interphalangeal, and wrist motion, which reduces stiffness 3
• Buddy taping to the 4th digit can provide additional stability 4
• Functional taping alone has been shown to result in quicker recovery than rigid immobilization in adults, though pediatric-specific data is limited 4

For Displaced Fractures Requiring Reduction

• Closed reduction under appropriate analgesia/sedation 2
• Immobilization in ulnar gutter cast or hand-based splint 2, 3
• Surgical fixation with percutaneous pinning is reserved for: 5
  • Fractures that cannot maintain acceptable alignment after closed reduction
  • Intra-articular fractures at the base with significant displacement
  • Open fractures after irrigation and debridement 1

Immobilization Duration and Follow-Up

• Duration of immobilization: approximately 3-4 weeks 6, 3
• Minimize follow-up imaging to only what will change management 1
• Clinical assessment can often be performed via telehealth for fracture checks in stable injuries 1
• Repeat radiographs at 1 week only if clinical concern for loss of reduction 1, 3

Critical Pitfalls to Avoid

• Do not over-treat pediatric metacarpal fractures - children have remarkable remodeling capacity, and accepting some angulation is preferable to surgical intervention in most cases 1
• Do not use prolonged rigid immobilization - this increases stiffness without improving outcomes 4, 3
• Do not miss rotational malalignment - this does not remodel and requires correction 2
• Ensure adequate analgesia - pediatric fractures are painful, and appropriate pain control improves compliance 6

Expected Outcomes

Studies in adults show that even boxer's fractures (5th metacarpal neck) treated with soft wrap without reduction have equivalent functional outcomes to cast immobilization 7. In a 6-year-old with even greater remodeling potential, conservative treatment should yield excellent functional and anatomical results by 6 months 4, 3.