Boxer's fracture: Difference between revisions
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==Evaluation== | ==Evaluation== | ||
[[File:Neck Fracture of the Fourth Metacarpal Bone.png|thumb|Boxer's Fracture]] | [[File:Neck Fracture of the Fourth Metacarpal Bone.png|thumb|Boxer's Fracture (4th metacarpal)]] | ||
[[File:Fractured5thMetacarpalHead2018.jpg|thumb|Boxer's Fracture (5th metacarpal)]] | |||
===Workup=== | ===Workup=== | ||
*AP and lateral hand x-ray | *AP and lateral hand x-ray | ||
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===Diagnosis=== | ===Diagnosis=== | ||
*Typically on plain hand x-ray showing fracture of the 4th or 5th metacarpal | *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== | ==Management== | ||
=== | {{General Fracture Management}} | ||
===Acute Reduction=== | |||
''Contingent upon angulation and rotation'' | ''Contingent upon angulation and rotation'' | ||
*Any rotational deformity should be reduced to allow proper hand function (seen as scissoring) | *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 | *Angulation >30° in the 4th digit or >40° in the 5th digit should be reduced | ||
{ | {{Metacarpal fracture goals}} | ||
===Immobilization=== | ===Immobilization=== | ||
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*Uncomplicated | *Uncomplicated | ||
**Buddy taping<ref>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 </ref> | **Buddy taping<ref>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 </ref> | ||
***Similar functional outcomes those randomized to plaster cast with earlier return to work<ref>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 </ref> | ***Similar functional outcomes those randomized to plaster cast with earlier return to work <ref>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 </ref> | ||
***Similar satisfaction and pain control as those randomized to plaster casting <ref>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 </ref> | |||
***Shorter ER Stay <ref>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 </ref> | |||
*Complicated: | *Complicated: | ||
**[[Forearm volar splint]] with extension over the head of the MCP joint provides equal effect and is better tolerated<ref>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.</ref> | **[[Forearm volar splint]] with extension over the head of the MCP joint provides equal effect and is better tolerated<ref>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.</ref> | ||
***Classically, the [[Ulnar Gutter Splint]] was recommended | |||
==Disposition== | ==Disposition== | ||
*Outpatient management for closed fractures that are distally neurovascularly intact | *Outpatient management for closed fractures that are distally neurovascularly intact | ||
=== | ===Indications for Subsequent Out-Patient Orthopedic Surgery=== | ||
*Intra-articular fracture | *Intra-articular fracture | ||
*Rotational malalignment of digit | *Rotational malalignment of digit |
Revision as of 08:49, 2 May 2020
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
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.