Boxer's fracture

Background

  • Fracture of the 4th or 5th metacarpal caused by an axial load, typically from punching a person or object

Clinical Features

  • Pain or swelling along the 4th or 5th metacarpals
  • Volar angulation of metacarpal or "missing 4th/5th knuckle"
  • Look for areas of skin breakdown which may signify a fight bite that can result in a closed fist infection if untreated

Differential Diagnosis

Hand and Finger Fractures

Evaluation

Boxer's Fracture

Workup

  • AP and lateral hand x-ray

Diagnosis

  • Typically on plain hand x-ray showing fracture of the 4th or 5th metacarpal
  • "Uncomplicated" defined as:
    • Minimally displaced
    • Closed
    • Isolated injury
    • Fracture angulation of <70 degrees

Management

General Fracture Management

Acute Reduction

Contingent upon angulation and rotation

  • Any rotational deformity should be reduced to allow proper hand function (seen as scissoring)
  • Angulation >30° in the 4th digit or >40° in the 5th digit should be reduced

Metacarpal Fracture (Post-Reduction) Goals

Finger Shaft Angulation (degrees) Shaft Shortening (mm) Neck Angulation (degrees) Rotational Deformity
Index & Long Finger 10-20 2-5 10-15 None
Ring Finger 30 2-5 30-40 None
Little Finger 40 2-5 50-60 None

Immobilization

See Diagnosis section for definition

  • Uncomplicated
    • Buddy taping[1]
      • Similar functional outcomes those randomized to plaster cast with earlier return to work[2]
  • Complicated:

Disposition

  • Outpatient management for closed fractures that are distally neurovascularly intact

Indications for Subsequent Out-Patient Orthopedic Surgery

  • Intra-articular fracture
  • Rotational malalignment of digit
  • Significantly displaced or angulated fractures (see above criteria)
  • Multiple metacarpal shaft fractures
  • Loss of stability from border digit during healing process

See Also

References

  1. Pellatt, R., Fomin, I., Pienaar, C., Bindra, R., Thomas, M., Tan, E., … Keijzers, G. (2019). Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of Emergency Medicine, 74(1), 88–97. doi: 10.1016/j.annemergmed.2019.01.032
  2. Pellatt, R., Fomin, I., Pienaar, C., Bindra, R., Thomas, M., Tan, E., … Keijzers, G. (2019). Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of Emergency Medicine, 74(1), 88–97. doi: 10.1016/j.annemergmed.2019.01.032
  3. Hofmeister EP, Kim J, and Shin AY. Comparison of 2 Methods of Immobilization of Fifth Metacarpal Neck Fractures: A Prospective Randomized Study. The Journal of Hand Surgery. 2008; 33(8):1362–1368.