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Boxers Fracture

From WikiSM

Other Names

  • 5th Metacarpal Fracture
  • Boxer's Fracture
  • Punch Fracture
  • Knuckle Fracture
  • Fifth Metacarpal Neck Fracture
  • Subcapital Metacarpal Neck Fracture
  • 5th metacarpal neck fracture

Background

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

History

  • The earliest reference in the literature referring to a 'Boxers fracture' is attributed to Hunter in 1970[1]

Epidemiology

  • Metacarpal fractures make up 35-40% of all hand injuries, 5th is most common [2]
  • Most commonly seen in young males, age 10-29[3]
  • 33% of hand fractures are metacarpals, the vast majority are 5th metacarpal[4]

Pathophysiology

Boxer's fracture mechanism and anatomic features[5]
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.[6]
Subcapital fracture of the fifth metacarpal (boxer's fracture). a) and b) AP and lateral views. The palmar axial malalignment can only be properly measured in the lateral view. c) The sagittal CT shows a palmar lateral offset in addition to the palmar axial deformity[7]

General

  • Most common fracture of the hand, typically seen in young males, typically a clenched fist/ punching injury
  • Defined as a fracture to the 5th metacarpal head or neck
  • Diagnosis is made radiographically
  • The vast majority of cases can be managed without surgery

Etiology

  • Occurs as a result of direct trauma to a clenched fist where energy is transferred through the fifth metacarpal axially
  • Proximal phalanx slides down over metacarpal head with axial loading of the 5th metacarpal
  • Mostly results in apex dorsal angulation due to the pull of the interosseous muscles of the hand

Anatomy of the 5th Metacarpal

Risk Factors

General

  • Young age
  • Male (95%)
  • Intentional punching/ acts of aggression
  • Contact and combat sports

Sports

  • Boxing[8]
  • Mixed Martial Arts

Differential Diagnosis

Differential Diagnosis Finger And Hand Pain

Clinical Features

Clinical example of boxers fracture with typical swelling of 5th MCPJ

History

  • Patients should describe some type of trauma, usually punching
    • Axial load on the MCP joint with the fist in flexion
  • They may be embarrassed or unwilling to admit they punched something/ someone
  • Report hand pain along the ulnar side, typically around the MCPJ
  • Delayed presentations are common, particularly with weekend injuries[9]
  • It is important to ask whether the patient struck another persons mouth (consider fight bite)

Physical Exam: Physical Examination Hand

  • Inspection can show eccymosis, swelling
    • Loss of the normal fifth knuckle prominence[10]
    • 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
    • Over the fifth metacarpal neck (just proximal to the MCP joint)
  • Range of motion is often limited by pain
  • Assess for "scissoring" of digits which suggests rotational component
  • Neurovascular exam is typically normal

Special Tests

  • There no widely accepted or validated special tests for a Boxers Fracture

Evaluation

Long axis ultrasound of the 5th metatarsal reveals cortical disruption with subtle volar angulation.[11]
Extra-articular transverse fracture through the neck of the 5th metacarpal bone with volar angulation[12]

Radiographs

  • Standard Radiographs Hand
    • Initial imaging modality of choice
    • Sufficient to make diagnosis
  • Findings
    • Classically minimally comminuted, transverse fracture of metaphysis
    • X-ray sensitivity for fifth metacarpal fractures is high (Sn ~77–95% depending on the study)[13]
    • Can miss adjcant fractures, intra-articular extension, rotational malalignment[14]

CT

  • Typically not indicated for routine acute metacarpal fractures
  • Can consider when[15]
    • Suspected intra-articular extension into the MCP joint
    • Equivocal radiographs where fracture is clinically suspected
    • Preoperative planning
    • Significant comminution requiring fracture characterization

Ultrasound

  • Ultrasound can be used to diagnose boxers fracture[16][17]
    • Highly accurate, radiation-free, bedside tool
    • 15% sensitivity and 96% specificity
    • Water bath technique can help
  • Useful for
    • Fracture diagnosis
    • Guided nerve block
    • Real-time reduction guidance

MRI

  • Generally not indicated for acute metacarpal fractures[18]
  • Primary role in hand trauma is evaluating soft-tissue injuries
  • Can consider for the following reasons
    • Suspected concomitant tendon or ligament injury at the MCP joint
    • Occult fracture when radiographs are negative (note: CT preferred)
    • Chronic pain or dysfunction

Classification

  • N/a

Management

Ulnar Gutter Brace

Fracture treatment with self-adherent wrap and strapping of the fourth and fifth fingers<[19]
Surgical techniques for boxer's fractures

Acute Management

  • Appropriate Analgesia
    • Consider ulnar nerve block
  • Reduction if needed (Jahss Maneuver)[20]
    • Flex the MCP and PIP joints to 90°
    • Apply dorsally directed pressure through the proximal phalanx to push the metacarpal head back into anatomic position
    • Uses the proximal phalanx as a lever arm, tightens the collateral ligaments to stabilize the reduction
  • Immobilization
  • Consider antibiotics if there are any breaks in skin that could come from the mouth

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

  • Duration: Typically 4-6 weeks
  • Ulnar Gutter Splint or ulnar gutter brace
    • Classic immobilization
  • Buddy taping
    • Reduces the risk of rotational deformity[22]
    • Bansal et al: patients reported a higher degree of patients satisfaction, less follow-up, and an earlier return to work[23]

Operative

  • Indications
    • Open fracture
    • Intra-articular
    • Rotational deformity/ malalignment (scissoring)
    • Significant displacement
    • Multiple fractures
    • Instability
    • Failure of conservative management
    • Patient-specific demands (e.g., professional athletes, manual laborers with high cosmetic/functional expectations)
  • Technique
    • Antegrade intramedullary pinning (bouquet technique)
    • Transverse (cross) pinning
    • Plate fixation (ORIF)
    • Headless compression screw (intramedullary)

Rehab and Return to Play

Rehab exercises for Boxer's Fracture

Phase 1: Protection and Edema Control (Weeks 0–3)

  • Goals: Control pain and swelling, Protect fracture, Prevent stiffness
  • Immobilization
    • Buddy taping or ulnar gutter splint (nonoperative)
    • K-wire fixation: splint until wire removal (~3–4 weeks)
    • Plate/IM nail fixation: removable splint with early motion as tolerated
  • Edema Management: Elevation, Finger pumping, Light compression wrap, Retrograde massage
  • Exercises
    • ROM of uninvolved joints
    • Gentle 5th finger MCP/IP ROM as tolerated
    • Tendon gliding exercises

Phase 2: Early Mobilization (Weeks 3–6)

  • Goals: Restore ROM, Improve hand function, Continue edema control
  • Criteria to Progress
    • Clinical fracture stability
    • K-wire removal if applicable
    • Transition out of rigid immobilization
  • Exercises
    • Composite fist and isolated MCP/IP ROM
    • Tendon gliding
    • Place-and-hold exercises
    • Wrist ROM
    • Blocking exercises
  • Allowed: Typing, Writing, Dressing, Light ADLs
  • Avoid: Power grip, Torque, Impact loading
  • Buddy Taping: Continue during activities as needed

Phase 3: Strengthening (Weeks 6–10)

  • Goals: Restore grip strength, begin resistance training, return to light work
  • Criteria to Progress: Radiographic healing, near-full ROM, minimal pain
  • Exercises
    • Grip strengthening with therapy putty
    • Pinch strengthening
    • Wrist strengthening
    • Pronation/supination resistance
    • Finger abduction/adduction resistance
  • Benchmarks
    • Grip strength ~70% by 6 weeks
    • Grip strength >90% by 12 weeks

Phase 4: Return to Activity (Weeks 10–16)

  • Goals
    • Restore full strength
    • Return to work and sport
    • Resume unrestricted activity
  • Exercises
    • Progressive grip strengthening
    • Sport-specific drills
    • Work hardening
    • Gradual impact conditioning

Rehab Exercise PDFs

Return to Play/ Work

  • The athlete should meet the following criteria[24]
    • Fracture is clinically and radiographically healed; no tenderness at the fracture site
    • Full, pain-free range of motion and grip strength are restored
    • Sport-specific skills can be performed without limitation
    • Protective taping or orthosis is used as appropriate to minimize reinjury risk
    • The athlete understands the risks and demonstrates psychosocial readiness for return

Prognosis and Complications

Prognosis

  • Most patients have good functional outcomes[25]
    • Higher when there is no rotational deformity or severe angulation
    • Higher when the fracture is managed appropriately
    • Most patients regain full function, with minimal long-term disability or pain
    • Most patients can reutrn to work/sport in a few weeks or months

Complications

  • Infection
    • 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
  • Reduced grip strength
  • Fracture related complications
    • Malunion or nonunion
    • Rotational deformity
    • Stiffness/ loss of ROM

See Also

Internal

External

References

  1. ↑ Hunter, J. M., and N. J. Cowen. "Fifth metacarpal fractures in a compensation clinic population." Journal of Occupational and Environmental Medicine 13.12 (1971): 603-604.
  2. ↑ Ashkenaze DM, Ruby LK. Metacarpal fractures and dislocations. Orthop Clin North Am 1992; 23:19.
  3. ↑ De Jonge, J. J., et al. "Fractures of the metacarpals. A retrospective analysis of incidence and aetiology and a review of the English-language literature." Injury 25.6 (1994): 365-369.
  4. ↑ Ip, W. Y., K. H. Ng, and S. P. Chow. "A prospective study of 924 digital fractures of the hand." Injury 27.4 (1996): 279-285.
  5. ↑ Aita, Marcio Aurelio, et al. "Intramedullary fixation with headless screws versus bouquet in unstable metacarpal neck fractures in active patients: A randomized study." Revista Brasileira de Ortopedia 56.06 (2021): 717-725.
  6. ↑ 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.
  7. ↑ Hesse, N., P. Reidler, and R. Schmitt. "Sportverletzungen des Daumens und der Finger." Die Radiologie 63.4 (2023): 284-292.
  8. ↑ Javed, M., S. Hemington-Gorse, and K. Shokrollahi. "A new recreational mechanism for the boxer’s knuckle: cause for concern?." The Annals of The Royal College of Surgeons of England 93.5 (2011): e55-e56.
  9. ↑ Gudmundsen, T. E., and L. Borgen. "Fractures of the fifth metacarpal." Acta radiologica 50.3 (2009): 296-300.
  10. ↑ Poolman, Rudolf W., et al. "Conservative treatment for closed fifth (small finger) metacarpal neck fractures." Cochrane Database of Systematic Reviews 3 (2005).
  11. ↑ 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.
  12. ↑ Case courtesy of Dr Fadi Ali, Radiopaedia.org, rID: 85147
  13. ↑ Wierer, Guido, et al. "The “Trigonometric Technique” for simple measurement of volar angulation in boxers’ fractures." Orthopaedics & Traumatology: Surgery & Research 106.8 (2020): 1653-1658.
  14. ↑ Comparison of the diagnostic accuracy of X-ray and computed tomography in patients with wrist injury
  15. ↑ Lee, Jun-Ku, et al. "The inter-and intra-observer reliability of volar angulation measurements in a fifth metacarpal neck fracture." Archives of Orthopaedic and Trauma Surgery 142.7 (2022): 1705-1713.
  16. ↑ Zhao, Wenjun, et al. "The value of ultrasound for detecting hand fractures: A meta-analysis." Medicine 98.44 (2019): e17823.
  17. ↑ 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.
  18. ↑ Torabi, Maha, et al. "ACR Appropriateness Criteria® acute hand and wrist trauma." Journal of the American College of Radiology 16.5 (2019): S7-S17.
  19. ↑ Aaken, Jan van, et al. "Outcome of boxer's fractures treated by a soft wrap and buddy taping: a prospective study." Hand 2.4 (2007): 212-217.
  20. ↑ Amsallem, L., et al. "Simplified internal fixation of fifth metacarpal neck fractures." Orthopaedics & Traumatology: Surgery & Research 104.2 (2018): 257-260.
  21. ↑ 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.
  22. ↑ Haughton, D. N., et al. "Principles of hand fracture management." The open orthopaedics journal 6 (2012): 43.
  23. ↑ Bansal, R., and M. A. C. Craigen. "Fifth metacarpal neck fractures: is follow-up required?." Journal of Hand Surgery (European Volume) 32.1 (2007): 69-73.
  24. ↑ Herring, Stanley A. "The team physician and return-to-play issues: a consensus statement." Medicine & Science in Sports & Exercise 34.7 (2002): 1212-1214.
  25. ↑ van Aaken, Jan, et al. "Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial." Archives of orthopaedic and trauma surgery 136.1 (2016): 135-142.
Created by:
John Kiel on 15 August 2019 21:03:08
Authors:
Last edited:
26 May 2026 15:59:57
Categories:
Trauma | Finger | Hand | Fractures | Featured
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