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Both MCP-flexion and MCP-extension casts are effective immobilization methods

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Both MCP-flexion and MCP-extension casts are effective immobilization methods

Vol: 2| Issue: 3| Number:84| ISSN#: 2564-2537
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A

Comparison of 2 Methods of Immobilization of Fifth Metacarpal Neck Fractures: A Prospective Randomized Study

J Hand Surg Am. 2008 Oct;33(8):1362-8

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81 patients from a naval medical center presenting with an acute isolated fracture of the fifth metacarpal neck were randomized to receive immobilization with either a short-arm cast with volar outriggers (SAC-VOR) with the metacarpophalangeal (MCP) joint in flexion, or immobilization with the MCP joint in extension using a cast with a 3-point mold about the fracture following closed reduction. The results indicated that both the MCP-flexion and MCP-extension casts were effective in maintaining fracture reduction, and no significant differences were observed between these two groups in terms of fracture healing, range of motion, grip strength and durability.

Publication Funding Details +
None disclosed

Risk of Bias


Reporting Criteria


Fragility Index


Was the allocation sequence adequately generated?

Was allocation adequately concealed?

Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?

Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?

Blinding Patients: Was knowledge of the allocated interventions adequately prevented?

Was loss to follow-up (missing outcome data) infrequent?

Are reports of the study free of suggestion of selective outcome reporting?

Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?

Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?

Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.




Outcome Measurements


Inclusion / Exclusion


Therapy Description



Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Fifth metacarpal neck fracture is a common injury, resulting from a longitudinal compression force applied to a hand in a clenched fist position. These fractures typically present with an apex dorsal angulation, and although some degree of angulation can be tolerated in the sagittal plane, too much angulation can result in difficulties performing gripping motions. Typical treatment of this injury involves closed fracture reduction followed by immobilization with metacarpophalangeal (MCP) joint in flexion. However, another method of immobilization involves immobilization of MCP joint in extension with 3-point molded cast. Reported advantages of this method are its ease of application and IP joint freedom resulting in improved tolerability. A recent systematic review demonstrated that among non-operative treatments there was no superiority of one over another, therefore, indicating the need for this study.

What was the principal research question?

What is the effect of immobilization with MCP joint in flexion in a short-arm cast with volar outriggers (SAC-VOR) compared to a 3-point mold cast with MCP joint in extension, on the maintenance of reduction of closed isolated fifth metacarpal neck fractures, measured over 3 months?

Study Characteristics -
81 young active-duty patients with an acute isolated fracture of the neck of the fifth metacarpal (average age, 25 years; range, 16–49 years. All patients were male except for one female in MCP-ext group).
SAC-VOR Group: Immobilization with MCP joint in flexion in short-arm cast with volar outriggers with ring, and small finger interphalangeal joints in extension (SAC-VOR) (n=40).
MCP-ext group: Immobilization with MCP joint in neutral extension, and cast with 3-point mold about fracture site (MCP-ext) (n=41).
Outcomes included disability (measured using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire), range of motion and grip strength (measured using dynamometer). Residual angulation was assessed on postreduction anteroposterior (AP) and lateral radiographs. The time for cast application and durability and tolerability of the cast were assessed.
RCT: Prospective; Single-blind
3 month follow up

What were the important findings?

  • No differences between the groups existed when comparing demographic data (p>0.05).
  • Application of the MCP-ext cast was significantly faster than the SAC-VOR cast (11 minutes vs. 15 minutes; p=0.025).
  • An equal number of casts in each group needed replacement throughout the treatment period (7 in each group).
  • DASH scores, range of motion, and grip strength were slightly improved in the MCT-ext group, but this superiority was not significant.
  • There was no significant difference between the two groups in terms of immediate postreduction angulation in the lateral plane (p=0.453); however, there was a statistically significant improvement in postreduction angulation in the AP plane in the SAC-VOR group (14 deg vs. 5 deg; p<0.005).
  • At 4 weeks, there was no significant difference in the maintenance of post-reduction alignment in either the lateral or AP plane, based on cast type or injury mechanism (AP plane, p=0.636, lateral plane, p=0.372).
  • At 4 weeks, radiographic callus and healing was evident in all patients.
  • Final MCP/PIP joint range of motion and grip strength was similar between the extension cast and MCP joint in flexion (SAC-VOR) groups (p>0.05 for all outcomes)

What should I remember most?

Both immobilization with MCP joint in extension and the MCP joint in flexion were effective casting methods resulting in similar fracture healing rates, range of motion, grip strength and durability. Advantages of the MCT-ext cast were quicker application and increased tolerability.

How will this affect the care of my patients?

This study suggests that patients that have undergone closed reduction of fifth metacarpal fractures will achieve similar results with either a MCP-extension or MCP-flexion cast for immobilization. Further studies with larger sample sizes can further support the results.

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