KEYWORDS fifth metacarpal neck fractures treatment radiological parameters functional outcomes TOPICS Medicine ABSTRACT Introduction and objective: Fifth metacarpal neck fractures are common, but optimal treatment remains controversial because anatomical reduction does not consistently predict functional recovery. The aim of the narrative review is to examine the relationship between radiographic deformity and patient-important outcomes and identified fracture characteristics relevant to treatment selection. Review methods: PubMed, Scopus, and Google Scholar were searched using terms related to fifth metacarpal fractures, radiographic alignment, treatment, and functional outcomes. Clinical studies and reviews reporting range of motion, grip strength, pain, DASH or QuickDASH scores, or return to activity, were qualitatively synthesized. Brief description of the state of knowledge: Operative treatment achieved more accurate correction of angulation and fracture alignment but did not consistently improve functional outcomes, pain, or return to work. In selected simple, closed, extra-articular fractures without malrotation, substantial shortening, or instability, residual angulation of 30–70° was often well tolerated. However, no universal safe angulation threshold could be established. Malrotation, substantial shortening, instability, displaced intra-articular fractures, and symptomatic impairment were more consistently associated with adverse functional outcome Summary: Treatment decisions should integrate radiographic findings with clinical assessment rather than rely on angulation alone. Functional reduction – alignment sufficient to preserve pain-free motion, effective grip, and return to activity – should be the primary objective. Operative treatment is most justified when deformity has demonstrable functional consequences, whereas isolated angulation with preserved finger alignment and hand function does not automatically require surgery.