What is the diagnosis and treatment for a 26-year-old male patient with a displaced fracture of the right fourth metacarpal bone, with approximately 1.29 centimeters of displacement, as shown on a preliminary x-ray (radiograph)?

From the Guidelines

This patient requires immediate orthopedic consultation for surgical management of his displaced right fourth metacarpal fracture, as the displacement of 1.29 cm exceeds the acceptable threshold and will likely need open reduction and internal fixation (ORIF) to restore proper alignment and function. The significant displacement suggests potential rotational deformity which, if left untreated, could lead to functional impairment, decreased grip strength, and overlapping digits during flexion 1. In the interim, provide pain management with scheduled acetaminophen 1000 mg every 6 hours and ibuprofen 600 mg every 8 hours as needed, unless contraindicated.

Initial Management

• Apply a ulnar gutter splint with the hand in the "safe position" (wrist slightly extended, metacarpophalangeal joints flexed at 70-90 degrees, and interphalangeal joints slightly flexed) to immobilize the fracture temporarily.
• Elevate the hand above heart level to minimize swelling.
• Ice can be applied for 20 minutes every 2 hours for the first 48 hours. Given the prison setting, ensure proper follow-up arrangements are made with the correctional facility's medical team and outside orthopedic specialists for definitive treatment, as the current evidence suggests that surgical fixation is necessary for fractures with significant displacement 1. The American College of Radiology also recommends radiography as the initial imaging for suspected acute hand and wrist trauma, which has already been done in this case 1.

From the Research

Treatment Options for Metacarpal Fractures

• The patient has a displaced fracture of the right fourth metacarpal with a displacement of about 1.29 cm, which may require surgical intervention to achieve proper alignment and stability 2, 3, 4, 5, 6.
• Open reduction and internal fixation (ORIF) is a common treatment approach for metacarpal fractures, which involves surgically exposing the fracture site, reducing the fracture, and stabilizing it with internal fixation devices such as plates, screws, or K-wires 2, 4, 6.
• Closed reduction and percutaneous pinning (CRPP) is another treatment option, which involves reducing the fracture without surgically exposing the fracture site and stabilizing it with percutaneous pins 4, 5.
• The choice of treatment approach depends on various factors, including the location and severity of the fracture, the patient's overall health, and the surgeon's preference 4, 5, 6.

Outcomes and Complications

• Studies have shown that both ORIF and CRPP can achieve good functional outcomes and low complication rates for metacarpal fractures 4, 5, 6.
• However, ORIF may be associated with a higher risk of complications, such as infection and nerve damage, compared to CRPP 5.
• The use of a thermoplastic splint as a surgical instrument can help to increase the surgeon's autonomy and streamline the patient care pathway during ORIF procedures 3.

Rehabilitation and Recovery

• Early mobilization and rehabilitation are crucial for achieving optimal functional outcomes after metacarpal fracture surgery 4, 6.
• Buddy splinting of the corresponding finger can enable immediate mobilization without weight bearing for 6 weeks, allowing for early recovery and restoration of unrestricted function 6.