title: Fractures of the fourth metacarpal.
abstract: OBJECTIVE
  To determine (a) the degree of shortening associated with isolated fourth metacarpal fractures and the functional outcome after operative or nonoperative (protocol of casting and outrigger) treatment (clinical portion), and (b) the role of the deep metacarpal ligament in minimizing shortening after isolated fourth metacarpal osteotomies simulating clinical fracture (cadaveric portion).
  
  
  METHODS
  This two-part study included a retrospective clinical portion and a cadaveric investigation.
  
  
  METHODS
  First, the records of twenty-four patients with isolated displaced oblique or spiral fourth metacarpal fractures without adjacent metacarpal fractures were retrospectively reviewed. The amounts of shortening after nonoperative (seventeen patients) and operative (seven patients) intervention were compared. Second, seven hands were studied to compare the length of intact fourth metacarpals to that after oblique osteotomies and after deep metacarpal ligament sectioning. The differences in shortening measurements were statistically analyzed using a paired t test.
  
  
  RESULTS
  There was no significant difference in mean initial shortening (+/-SD) between operative and nonoperative patients (2.65 +/- 1.85 mm vs. 4.19 +/- 1.83 mm, respectively; p < 0.09; overall average shortening, 3.1 mm) or functional outcome. The cadaveric study documented the important role of the deep metacarpal ligament in minimizing fourth metacarpal shortening. Fourth metacarpals osteotomized with an intact deep metatarsal ligament had significantly less mean shortening (+/-SD) than those with a sectioned deep metacarpal ligament: 2.1 versus 5.8 mm, respectively (p < 0.001).
  
  
  CONCLUSIONS
  In the absence of unreducible rotational malalignment, fourth metacarpal fractures may be adequately treated nonoperatively with a protocol of casting and outrigger.
authors.affiliation: Section of Orthopaedics, R. Adams Cowley Shock Trauma Center/University of Maryland Medical System, Baltimore, MD 21201-1595, USA.
authors.forename: W A
authors.initials: WA
authors.lastname: Eglseder
authors.forename: P J
authors.initials: PJ
authors.lastname: Juliano
authors.forename: R
authors.initials: R
authors.lastname: Roure
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001696:Biomechanical Phenomena; D002102:Cadaver; D005260:Female; D005385:Fingers; D005593:Fracture Fixation, Internal / Q000009:adverse effects; D050723:Fractures, Bone / Q000628:therapy*; D006801:Humans; D008023:Ligaments, Articular / Q000473:pathology*; D008297:Male; D008662:Metacarpophalangeal Joint / Q000473:pathology*; D008663:Metacarpus / Q000293:injuries* / Q000601:surgery; D008875:Middle Aged; D008962:Models, Theoretical; D009984:Orthopedic Fixation Devices; D010027:Osteotomy; D012189:Retrospective Studies