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A radiographic classification system of fifth metacarpal fractures
Blair Peters, MD; Jennifer L. Giuffre, MD
University of Manitoba, Winnipeg, MB, Canada

Purpose: The current literature on 5th metacarpal fractures is riddled with differing opinions and a lack of consensus regarding ideal management. Due to this uncertainty, we aimed to review the demographics and create a classification system of 5th metacarpal fractures based on the rates of surgical intervention and radiographic characteristics to guide the practitioner in the management of these injuries.
Methods: 100 x-rays of patients with 5th metacarpal fractures were reviewed. Demographics and radiographic data collected included fracture location, pattern, amount of displacement, angulation, shortening, comminution and other associated fractures or dislocations. It was also assessed whether patients underwent a closed reduction or operation (percutaneous pinning or open reduction internal fixation).
Results: 70% of patients were male and 30% of patients were female. The mechanism was a punch injury in 80% of cases. 48.3% of fractures were Boxerís (neck) fractures. 15% of cases had multiple fractures on radiograph. 57.5% of all patients underwent a closed reduction and 18% of patients had surgical management of their 5th metacarpal fracture. Fracture patterns found to carry a higher likelihood of surgical intervention were spiral oblique fractures and transverse midshaft fractures requiring surgery in 80% and 33.33% of cases respectively. Most of the transverse midshaft fractures fixed operatively were angulated greater than 30 degrees. No neck fractures with angulation <40 degrees were fixed operatively. Patients with multiple fractures had a higher chance of undergoing an operative procedure than patients without multiple fractures. Based on these findings the following classification scheme was created.

Type 1 - Non-displaced fracture

Type 2 - Head/neck fractures

a - < 40 Degrees angulation

b - > 40 Degrees angulation

Type 3 - Shaft fractures

a - < 30 Degrees angulation

b - > 30 Degrees angulation

Type 4 - Base fractures

a - Extra-articular 

b - Intra-articular

Type 5  - Spiral/oblique Fractures

Type 6 - Multiple fractures/fracture-dislocations

Conclusions: Certain fracture patterns (Type 3b and Type 5) appear to have higher rates of surgical management. This classification system allows practitioners to identify radiographic patterns more likely to require surgical intervention and therefore guide referrals to plastic surgery. For low risk radiographic types physical examination and patient demographics should guide the need for operative intervention.
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