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Three Part Question

[How much angulation] can be [managed conservatively with neighbour strapping] in [patients with 5th MC neck fracture]?

Clinical Scenario

A 25yrs old gentleman presents to the ED after punching into a wall, xrays show boxer fracture with 60degrees volar angulation. Can he be managed conservatively with neighbour strapping or he needs surgery?

Search Strategy

Embase, 1980- May 2012
Medline, 1950- May 2012
Cinhal, 1981- May 2012
Google scholar
Cochrane library
Trip data base

5th MC fracture
5th MC fracture and management
5th MC fracture and neighbour strapping

Search Outcome

We had 56 hits and 6 papers were found to be relevant to our 3 part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Harding IJ et al 2001 UK	65 patients with closed 5th MC neck fracture, angulation < 40 degrees and no rotational deformity were randomised to NS / Metacarpal brace group.	RCT	A comparison was made for ROM, pain and return to work time between two groups.	Patients with brace had less pain (p=0.01), slightly better range of movements (p=0.03) and early return to work (p=0.007)	Small study, single centre, no validated scales been used.
Markwin G et al 2003 Netherlands	40 consecutive patients with 5th MC fracture and <70 degree angulation were randomly allocated to ulnar gutter/ pressure dressing groups.	RCT	A comparison was made for ROM and satisfaction between two groups.	There were no statistically significant differences between both groups regarding ROM (RR=0.95, CI=0.6-1.5), Pain (RR=0.81, CI= 0.6-1.1), and satisfaction (RR=1.0, CI= 0.6-1.7).	Small group, single centerno validated scale for assessment.
Bansal R, Craigen MA 2006 UK	78 consecutive patients with 5th MC fracture and <70 degree angulation were allocated to plaster/ NS groups.	Comparative, prospective study.	A comparison was made for satisfaction and return to work between two groups.	Patients reported better satisfaction with NS (p=0.04), and without regular follow up (p<0.01). the time to return was 5weeks and 2.7 weeks respectively (p<0.01)	Small number, single centre
Theeuwen GA, Lemmens JA, van Niekerk JL 1991 netherlands	71 patients with isolated 5th MC neck fracture and angulation 0-70 degrees were included.	Retrospective, comparative study	Comparison between reduction and no reduction for degree of angulation, reduction and eventual subjective results.	Reduction produced significant initial improvement (p<0.05) but increased after plaster removal.	Small group, retrospective, single centre, significant follow up loss.
Aaken JV 2007 Switzerland	25 patients with 5th MC neck fracture and 30-75 degrees angulation were enrolled in the study.	Prospective, observational study.	Assessment was made to evaluate ROM, grip strength, pain, and limitation of daily activities.	There was no clinically significant loss in the ROM, no loss in grip strength and patients were very satisfied.	Small number, single centre. Significant loss in follow up.
Hannu O et al 1999 Finland	29 patients with 5th MC neck fracture and <70 degrees angulation were enrolled in the study for functional vs reposition and splinting group.	Prospective, comparative study	At the follow-up examination the union and angulation of the fracture were estimated from radiographs. The range of movement (ROM) of the fifth MCP and PIP joints were measured. The grip force of both hands was recorded.	The range of movement of MCP (p = 0.02) and PIP (p = 0.01) joints were higher in the functional group at four weeks. The grip force of the affected hand was considerably better in the functional group at four weeks (p = 0002)	Small number, single centre

Comment(s)

The available evidence is level 1&2. It does suggest that there is hardly any difference in the out come while managing patients with 5th MC neck fractures up to 70 degrees angulation.

Clinical Bottom Line

Patients with closed 5th MC neck fracture, up to 70degrees angualtion and without rotational deformity can be managed conservatively with neighbour strapping.

References

1. Harding I.J. Parry D and Barrington R.L. The Use Of A Moulded Metacarpal Brace Versus Neighbour Strapping For Fractures Of The Little Finger Metacarpal Neck. Journal of Hand Surgery (British and European 2001, 261-263.
2. Markwin G.Statius Muller, Rudolf W et al Immediate mobilization gives good results in boxer's fractures with volar angulation up to 70 degrees: a prospective randomized trial comparing immediate mobilization with cast immobilization Archives of Orthopaedic and Trauma Surgery (2003), 534-537
3. Bansal R, Craigen MA Fifth metacarpal neck fractures: is follow-up required? J Hand Surg Eur 2007 Feb;32(1):69-73
4. Theeuwen GA, Lemmens JA, van Niekerk JL Conservative treatment of boxer's fracture: a retrospective analysis Injury. 1991 Sep;22(5):394-6
5. Aaken JV. Outcome of Boxers fracture treated by a softwrap and buddy tapping: A prospective study. Hands 2007 december;2(4): 212-217
6. Hannu O. M. Kuokkanen, Soili K et al. Treatment Of Subcapital Fractures Of The Fifth Metacarpal Bone: A Prospective Randomised Comparison Between Functional Treatment And Reposition And Splinting. Scand J Plast Reconstr Hand Surg 33: 315–317, 1999