Recently I fractured my base 5th metacarpal when hit a bump in the road and fell off my bicycle, landing on my right hand. The fracture was non displaced and closed. I was fitted with a ulnar gutter splint at the urgent care center and also by an orthopedic doctor that I visited within the first two weeks following the fracture.
At this point at week 2, I followed up with a hand specialist who placed me in a metacarpal splint/brace that he molded around my hand. To me, this is more uncomfortable than the ulnar gutter because there is more movement allowed (especially by the fingers) that causes sensations at the fracture site. Sometimes its a slight tingle, other times its a slight throbbing pain lasting for a minute or so -- this occurs when I reach with or twist my small finger , forgetting that I;m using an injured hand. This is despite the fact that I have my 4th and 5th fingers taped together.
I reported the movement and sensations to the doctor, but he says movement is important in the hand, so it does not stiffen up and cause my fingers to lose mobility (permanently?) , and that in his experience , this type of injury heals just fine with this type of brace.
However, I would prefer to have my hand immobilized for the remaining three weeks with the ulnar gutter splint and be assured that the bone is protected and heals completely, and then be concerned with tendons, etc, when I remove it -- when I will be glad to move and stretch my hand and fingers as much as I can.
So, Is there any concern about permanent stiffness/tissue atrophy with the ulnar gutter? Is there anyone with experience with using a metacarpal brace ? Any comparison between this and the ulnar gutter cast, which seems to be the indicated form of treatment for the boxer's fracture?
A fracture at the base of the fifth metacarpal is not the same as a boxer's fracture. They are two different animals.
A boxer’s fracture is located at the neck of the metacarpal, as such, to control the small distal fragment, the metacarpalphalangeal joint (MCPJ) has to be immobilized. The usual treatment for a boxer’s fracture is a cast or splint, with the ring and small fingers in the James position (the MCPJ is flexed to 90 degrees, and the interphalangeal joints of the fingers are kept extended). The reason for the James position (besides to control the fracture) is to help reduce the problems with post immobilization stiffness in the joints. Hands immobilized in incorrect positioning can lead to devastating results in some patients.
Thus, there has been some research looking into whether or not certain metacarpal fractures can be treated without having to immobilize the fingers. So, in some metacarpal midshaft fractures a functional metacarpal brace (also called a Galveston brace) can be used. Some hand surgeons prefer the brace over the ulnar gutter cast/splint in James position, because the fingers do not get stiff. However, in one study of the brace, it was found that patients do not prefer the Galveston. In this study (comparing the Galveston to a plaster cast in James position) only 42% of the patients in the metacarpal-brace group completed the treatment, in contrast to 81% of the patients in the plaster-cast group. Reduction of mobility in the fingers was more frequent in the plaster-cast group, but at three months postinjury no reduction of mobility was observed in either group.
As to the treatment of fifth metacarpal base fractures, it is mainly up to the surgeon's and patient’s preference. These fractures are usually treated with an ulnar gutter splint or a well molded short arm cast, with the ring and small fingers taped together. We have found that most patients prefer the well molded short arm cast. By molding the cast well in the palmar arch and placing the wrist in slight extension, the fracture is well maintained. Taping the fingers provides rotational support for the small finger. This immobilization allows motion at the finger joints, which is always preferred by hand surgeon.
In some cases, especially where the fracture is extremely comminuted and unstable (the metacarpal shaft fragment does not want to stay reduced, always moving away from the base fragments, due to the pull of the muscles), an ulnar gutter cast with the fingers in James position is required. But, usually, if the fracture is this unstable, surgery is done to reduce the fracture and pin the fragments.
Reduction of the articular fragments is very important in base of fifth metacarpal fractures. These fractures are quite often intra-articular. If the joint is not reduced well, then the incidence of traumatic arthritis goes up significantly.
Usually, by the time a patient reaches the third week or so of immobilization of hand fractures, the fracture has laid down enough osteoid for the fracture to become “sticky”. When this occurs, there is minimal motion of the fragments. Immobilization after this period is just for comfort, till the osteoid is calcified into callus, and the fracture is united.
But, if you are having significant problems with the metacarpal splint, you might ask to have a well molded short arm cast put on. Again, this is a very frequent way to treat these fractures. You’d be surprised how well these hold base of fifth fractures. But, the cast has to be well molded in the arch and wrist. It can’t be just a routine short arm cast that some orthopedic technicians (cast techs) put on. We usually do this casting ourselves, rather than let the cast techs do it. Also, we use plaster, not fiberglass, because you just cannot mold fiberglass well enough, like you can with plaster.
However, if this does not do the trick, then you might have to tell the surgeon that you cannot tolerate the immobilization and would prefer to deal with the post immobilization stiffness. Most patients can get their motion back after immobilization (especially if they were immobilized properly), but there are a few rare cases that have permanent stiffness. You just have to be aware of the possibility.
Do you suppose that the tiny bit of "wiggle room" within my fiberglass Galveston brace means that I do not or did not have proper immobilization of the broken bone, thus explaining the weird sensations e.g. occasional aches and tingles at the fracture spot (after moving my hand certain ways)?
Or when you talk about comfort does it instead refer to the squeezing feeling of the metacarpal brace? (It is bad -- could have been helped by some more padding.
I ask because I wonder if arthritis or adherence issues could develop in a bone that experienced these small bits of motion while it was healing?
Again, its a minor base of fifth break, with the fiberglass metacarpal splint bent and centered around it. I hope that's not too unusual form of treatment, and there is evidence already existing to support its use.
Would you know the name of that study off hand? Thank you again for all the helpful info.
The Galveston brace is a pre-made, pre-formed padded plastic brace, which is usually used for midshaft metacarpal fractures. It works on the principle of the three point bend. By placing points of stress on the bone (two on the concave side, one on the convex side), the bone will be reduced. This is why they are usually only used in midshaft metacarpal fractures. Boxer’s and base fractures do not have large enough fragments to be able to apply the three point bend principle. (You can find pictures of this brace if you Google “Galveston brace pictures”.)
But, you never know what some surgeons will use. Anyways.
You state that you fracture was a “minor” one. Is that meaning that it is nondisplaced (the bone is basically as it should be, just with a “crack” across it, also called a hairline fracture)? If so, these fractures do not need a lot of immobilization, except basically to hold the area still until the fracture is united. So, just about anything will work. In these cases, we usually just put the patient is a comfortable commercial wrist splint.
But, if there is any displacement of the fracture or if it goes into the joint, these we treat these base of fifth MC fractures in the well molded plaster cast. If there is a lot of displacement or the joint surface is disrupted, then we operate on all of these. This is to reduce the chance of developing traumatic arthritis in the future. Any fracture that goes into a joint has the potential of causing traumatic arthritis (no matter how it is treated), but if the joint surface remains unlevel, then the chances go way up.
Usually, if a fracture is not immobilized properly, the patient will feel the bones moving, which will cause sharp, intense pain right at the fracture site. It may be that the tingling/aching you have when you move your hand in a certain way, could be from the fragments moving. But, again, usually when the fragments move it causes sharp, intense pain.
There is often aching, pulling, tingling, throbbing, “weird” sensations around a fracture site as it is healing. This is mainly due to stretching of the scar tissue that forms around a fracture. Remember that you do not break just the bone, but that all of the soft tissues around the break are also damaged. These soft tissues have to heal, and that is with scar tissue. This scar tissue has to mature and soften. While that is going on, patients will often complain of some strange sensations around the fracture site.
As to the squeezing, that should not be occurring. All immobilization has to be comfortable. Sure, acute fractures hurt, but the cast/splint/brace/whatever that is applied to immobilized the fracture should make the patient comfortable, not cause more problems. The immobilization should not rub or pinch whatsoever.
A little motion at the fracture site is okay, as long as the joint surface is maintained. If your fracture does not involve the joint, then a little motion won’t hurt anything. In fact, a little motion can stimulate the body to lay down callus to stop the motion, thus healing the fracture a little faster. However, in fractures that involve the joint, you do not want any motion that disrupts the joint surface.
The following articles may be of interest to you. The first one is the one that I was speaking of. But, these are just a few of the multitude of articles on the treatment of metacarpal fractures.
If you are having a lot of discomfort with the brace, or you are concerned about it, speak with your hand surgeon again. If may be that you would do better in a plaster cast or splint. Good luck.
“Functional fracture bracing in metacarpal fractures: the Galveston metacarpal brace versus a plaster-of-Paris bandage in a prospective study.”
Sorensen JS, Freund KG, Kejla G
Journal of Hand Therapy, 1993 Oct-Dec;6(4):263-5
“Clinical Results of Intraarticular Fractures of the Base of the Fifth Metacarpal Treated by Closed Reduction and Cast Immobilization”
Lundeen JM, Shin AY
Journal of Hand Surgery, British & European Volume, 2000 June;25(3); 258-261
“Use of a Stacked Galveston Functional Brace for Treatment of Multiple Adjacent Metacarpal Fractures”
Klibanoff JE, Potter BK
Orthopedics, 2008 Jan; 31(1)
“Initial treatment of closed metacarpal fractures: A controlled comparison of compression glove and splintage”
McMahon PJ, Woods DA, Burge PD
Journal of Hand Surgery: British & European Volume, 1994 Oct; 19(5):597-600
“Functional bracing of fractures of the second through fifth metacarpals”
Viegas SF, Tencer A, Woodard P, Williams CR
Journal of Hand Surgery: American Volume, 1987 Jan;12(1):139-43
“Intra-articular fractures at the base of the fifth metacarpal: A clinical and radiographical study of 64 cases”
Kjaer-Petersen K, Jurik AG, Petersen LK
The Journal of Hand Surgery: British & European Volume, 1992 April; 17(2):144-147
It is possible that an additional week will show more callus, but the most important thing to look at is how you are doing clinically.
It is not uncommon for fracture lines to remain visible in the fingers and hand for an extended period of time, even after the fracture is clinically healed.
So, there is no need to keep a patient immobilized, just because a fracture line is still visible, if he/she is clinically healed (no pain at the fracture site with palpation or range of motion).
So, if you want to wait till the sixth week to see your surgeon, that would be fine. But, again, it is your clinical presentation that is of more importance than what your fracture actually looks like on the x-rays.
ive fractured my 5th metacarpal also , i had a splint for 4 weeks , 7 weeks on the side of my hand is still swollen , and i cant make a fist yet , also all the joints hurt in my fingers they are sore to bend -- i had physio 2 times -- yippee , feel i need a bit more , but it was painful so in a way glad they discharged me and not -- week by week i see a small difference , im back to work on light duties but i feel it after 9 hours a day in my fingers not the fracture , also not got full movement of wrist yet -- we will get there it takes time