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 Fracture Types
Evaluation
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 pain management
- Open fractures require immediate IV antibiotics and urgent surgical washout
- Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
- Consider risk for compartment syndrome
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
- Video on how to perform reduction
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
- Complicated:
- Forearm volar splint with extension over the head of the MCP joint provides equal effect and is better tolerated[5]
- Classically, the Ulnar Gutter Splint was recommended
- Forearm volar splint with extension over the head of the MCP joint provides equal effect and is better tolerated[5]
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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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.