Episode 158.0 – Boxer’s Fracture

In this episode, we discuss Boxer's fractures and how to best manage them in the ED.

March 8th, 2019 Download One Comment Tags: ,

Podcast Video

Show Notes

Background:

  • 40% of all hand fractures
  • A metacarpal fracture can occur at any point along the bone (head, neck, shaft, or base)
  • “Boxer’s” fractures classically at neck
  • Most common mechanism: direct axial load with a clenched fist
  • Most common metacarpal injured is the 5th
  • A majority of these injuries are isolated injuries, closed and stable

Examination:

  • Ensure that this is an isolated injury
  • May note a loss of knuckle contour or shortening
  • A thorough evaluation of the skin is important
    • Patients may also have fight bites and require irrigation and antibiotics
  • Tender along the dorsum of the affected metacarpal
  • Evaluate the range of motion as the commonly seen shortening results in extension lag
    • For every 2 mm of shortening there is going to be a 7 degree decrease in ability to extend the joint
  • Check rotational alignment of digits with the MCP and PIP at 50% flexion.
    • Partially clench their fist and ensure that the axis of each digit converges near the scaphoid pole / mid wrist
  • Deformity is often seen due to the imbalance of volar and dorsal forces
    • Dorsal angulation
  • AP, lateral and oblique views should be obtained on XR
  • The degree of angulation is estimated with the lateral view
    • NB: Normal angle between the metacarpal head and neck is 15 degrees

Management:

  • Most may be splinted with an ulnar gutter splint
    • Must be closed, not significantly angulated, and not malrotated
  • When splinting, place the wrist in slight extension, MCP (knuckles) at 90 degrees and the DIP and PIP in a relaxed, slightly flexed position
  • A closed reduction is indicated if there is significant angulation

Referral:

  • May have mild deformity or decreased functionality and strength in hand grip after this injury
  • Emergent evaluation if:
    • Open fracture
    • Neurovascular compromise

Follow up:

  • Refer to hand specialist
    • Within 1 week if fractures of 4thand 5thmetacarpals with angulation
    • 3 to 5 days if the 2ndand 3rd metacarpalsare affected
    • Immobilized for three to four weeks in splint
    • Healing may take up to six weeks

Take Home Points:

  • This is one of the most common fractures we will see as emergency physicians
  • When evaluating these patients, ensure that this are no other more severe, life-threatening injuries, and pay particular attention to the skin exam so that you do not miss a fight-bite
  • Reductions may be required if there is significant angulation, which is guided by the 20, 30, 40 rule
  • Finally, emergent specialist evaluation is indicated if there is an open fracture or evidence of neurovascular compromise

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