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Boxers Fracture

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Other Names

  • 5th Metacarpal Fracture
  • Boxer's Fracture

Background

  • This page refers to a 5th metacarpal fracture, a common hand injury often termed a 'Boxer's Fracture'

History

Epidemiology

  • Metacarpal fractures make up 35-40% of all hand injuries, 5th is most common [1]

Pathophysiology

Images from a 32-year-old male patient with a fifth metacarpal fracture of the right hand. A and B, Ultrasound images of the fifth metacarpal fracture before (A) and after (B) reduction. Radiographic assessment of the fifth metacarpal fracture before (C) and after (D) reduction. Arrows indicate fracture site; and M5, fifth metacarpal.[2]
  • General
    • Typically a clenched fist/ punching injury
    • Proximal phalanx slides down over metacarpal head with axial loading of the 5th metacarpal
    • Defined as a fracture to the 5th metacarpal head or neck

Risk Factors

  • Male (95%)

Differential Diagnosis


Clinical Features

Long axis ultrasound of the 5th metatarsal reveals cortical disruption with subtle volar angulation.[3]
  • History
    • Patients should describe some type of trauma, usually punching
    • They may be embarrassed or unwilling to admit they punched something/ someone
    • Report hand pain along the ulnar side, typically around the MCPJ
  • Physical Exam: Physical Examination Hand
    • Inspection can show eccymosis, swelling,
    • Important to evaluate for deformities, especially rotational deformities
    • Breaks in skin or open wounds that may suggest a 'fight bite'
    • Palpation reveals tenderness, sometimes bony crepitus
    • Range of motion is often limited by pain
    • Assess for "scissoring" of digits which suggests rotational component
    • Neurovascular exam is typically normal

Evaluation

Extra-articular transverse fracture through the neck of the 5th metacarpal bone with volar angulation[4]

Radiographs

  • Standard Radiographs Hand
    • Sufficient to make diagnosis
  • Findings
    • Classically minimally comminuted, transverse fracture of metaphysis

Ultrasound

  • Ultrasound can be used to diagnose boxers fracture
    • 5% sensitivity and 98.3% specificity [5]
    • Water bath technique can help

Classification

  • N/a

Management

Acute Management

  • Appropriate Analgesia
  • Reduction if needed
    • Consider ulnar nerve block
  • Immobilization

Nonoperative

  • Indications
    • The vast majority of cases can be managed nonsurgically
    • Stable, extra-articular
    • Can tolerate
      • Shaft Angulation: 40°
      • Shortening: 2-5 mm
      • Neck Angulation: 50 - 60°
  • Immobilization
    • Ulnar Gutter Splint (plaster or removable depending on patient)
    • Typically 4-6 weeks
    • Can ween to buddy taping

Operative

  • Indications
    • Open
    • Intra-articular
    • Rotational deformity
    • Significant displacement
    • Multiple fractures
    • Instability
  • Technique
    • ORIF

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Most patients have good functional outcomes

Complications

  • So-called "fight bite". clarify etiology of any breaks in skin that may be caused by teeth, if so treat empirically to cover oral flora
  • Tendon Laceration
  • Neurovascular Injury
  • Acute Compartment Syndrome

See Also


References


  1. Ashkenaze DM, Ruby LK. Metacarpal fractures and dislocations. Orthop Clin North Am 1992; 23:19.
  2. Shen, Suhong, Xiaohui Wang, and Zhuo Fu. "Value of Ultrasound‐Guided Closed Reduction and Minimally Invasive Fixation in the Treatment of Metacarpal Fractures." Journal of Ultrasound in Medicine 38.10 (2019): 2659-2666.
  3. Aksay E, Yesilaras M, Kılıc TY, et al. Sensitivity and specificity of bedside ultrasonography in the diagnosis of fractures of the fifth metacarpal. Emergency Medicine Journal 2015;32:221-225.
  4. Case courtesy of Dr Fadi Ali, Radiopaedia.org, rID: 85147
  5. Blaivas, Michael, et al. “Water bath evaluation technique for emergency ultrasound of painful superficial structures.” The American journal of emergency medicine 22.7 (2004): 589-593.
  6. Pellatt R, Fomin I, Pienaar C, Bindra R, Thomas M, Tan E, Mervin C, Zhang P, Keijzers G. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Ann Emerg Med. 2019 Jul;74(1):88-97. doi: 10.1016/j.annemergmed.2019.01.032. Epub 2019 Mar 8. PMID: 30853124.
Created by:
John Kiel on 15 August 2019 21:03:08
Authors:
Last edited:
26 June 2022 22:36:13
Categories:
Trauma | Finger | Hand | Fractures