What is the management plan for a non-displaced fracture of the 5th metacarpal, including diagnostic tests, medications, consults/referrals, patient education, and follow-up care?

Management of Non-Displaced 5th Metacarpal Fracture

Non-displaced 5th metacarpal fractures should be managed non-operatively with a hand-based functional splint or buddy strapping, allowing immediate finger motion and early return to activities, with follow-up imaging at 1-2 weeks to confirm maintained alignment. 1, 2

Diagnostic Tests

Initial Imaging

• Obtain standard hand radiographs (PA, lateral, and oblique views) to confirm non-displacement and assess for angulation, rotation, and shortening 3
• Acceptable criteria for non-operative management include: no joint involvement, no malrotation, angulation less than 30-70 degrees (most studies accept up to 70 degrees for 5th metacarpal), and shortening less than 5mm 4, 2

Follow-up Imaging

• Repeat radiographs at 1-2 weeks after initial treatment to detect any loss of reduction early 5
• Close radiographic monitoring is essential throughout the healing period to ensure proper alignment is maintained 5

Medications

Pain Management

• Provide appropriate pain relief throughout the treatment period, as inadequate pain control leads to poor outcomes 6, 5
• NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily) for acute pain management
• Consider short-term opioid analgesics (3-5 days) for severe initial pain if NSAIDs are insufficient

Immobilization Strategy

Splinting Approach

• Apply a hand-based functional splint that allows metacarpophalangeal (MCP), interphalangeal (IP), and wrist motion - this is superior to traditional casting 1
• Alternative: Buddy strapping with a Futura splint provides good functional results 2
• Avoid full hand/forearm casts that immobilize all joints, as this increases stiffness risk 1
• Average splint duration is approximately 24 days (3-4 weeks) 1

Immediate Mobilization Protocol

• Begin finger motion immediately after splint application to prevent edema and stiffness 7, 5
• Early finger and hand motion exercises are essential even during the immobilization period 7
• The functional splint design allows continued use of the hand for most activities 1

Consults/Referrals

Orthopedic/Hand Surgery Referral

• Refer immediately if: open fracture, significant angulation (>70 degrees), malrotation evident on exam, neurovascular compromise, or multiple metacarpal fractures 2, 3
• Consider referral for displaced fractures or those with intra-articular involvement 8

Occupational Therapy

• Refer at 1-2 weeks for formal hand therapy if patient shows early stiffness or difficulty with finger motion 7
• Aggressive finger and hand motion exercises should begin once immobilization is discontinued 7

Patient Education

Activity Modifications

• Most patients can continue working without missing days, even with dominant hand injuries 1
• 20 out of 24 employed patients in one study returned to work immediately with functional splinting 1
• Avoid direct impact or forceful gripping during the healing period (4-6 weeks)

Expected Outcomes

• Educate about disease burden, healing timeline (typically 4-6 weeks), and importance of follow-up 7
• Warn about signs of complications: increasing pain, numbness, color changes, or finger malrotation 3
• Delayed mobilization results in stiffness and suboptimal functional recovery 5

Fall Prevention (if age >50)

• Every patient aged 50 years and over must be systematically evaluated for subsequent fracture risk 7
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) 7
• Vitamin D 800 IU/day reduces non-vertebral fractures by 15-20% and falls by 20% 7

Follow-up Care

Timeline

• Week 1-2: Clinical and radiographic follow-up to confirm maintained alignment 5, 1
• Week 3-4: Remove splint if radiographs show healing; begin aggressive range-of-motion exercises 7, 1
• Week 6: Final clinical assessment to ensure full finger motion and grip strength recovery

Rehabilitation Protocol

• Early postfracture physical training and muscle strengthening should begin once splint is removed 7, 5
• Long-term balance training and fall prevention for patients over 50 years 7
• Physical therapy referral if persistent stiffness or weakness at 4-6 weeks 7

Secondary Fracture Prevention (Age >50)

• Coordinate with primary care for DXA scanning of spine and hip 7
• Consider pharmacological treatment (alendronate or risedronate as first-line) if high fracture risk identified 7
• Implementation requires coordination between orthopedics, primary care, and potentially rheumatology/endocrinology 7

Common Pitfalls

• Avoid over-immobilization: Traditional forearm casts that restrict all finger motion lead to unnecessary stiffness 1
• Don't accept closed reduction for displaced 5th metacarpal fractures: These are inherently unstable and reduction is often unsuccessful 4
• Avoid high-pulse vitamin D dosing in elderly patients: This increases fall risk rather than preventing it 7
• Don't skip follow-up imaging: Three out of 30 patients in one study showed alignment changes that required monitoring 1