Boxer's fracture: Difference between revisions

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==Background==
==Background==
*Fracture of the fourth or fifth metacarpal bones caused by an axial load, typically from punching a person or object.
*Fracture of the 4th or 5th metacarpal caused by an axial load, typically from punching a person or object


==Clinical Features==
==Clinical Features==
*Pain or swelling along the fourth or fifth metacarpals
*Pain or swelling along the 4th or 5th metacarpals
*Volar angulation of metacarpal or "missing 4th/5th knuckle"
*Volar angulation of metacarpal or "missing 4th/5th knuckle"
*Always look for areas of skin breakdown, as these may signify a [[Fight Bite]].
*Look for areas of skin breakdown which may signify a fight bite that can result in a [[closed fist infection]] if untreated
 
==Imaging==
*Typically seen on AP or lateral hand radiographs
[[File:Neck Fracture of the Fourth Metacarpal Bone.png|Boxer's Fracture]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Hand and finger fractures DDX}}
{{Hand and finger fractures DDX}}
==Evaluation==
[[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===
*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==
==Management==
*Indications for reduction are contingent upon angulation and rotation.
{{General Fracture Management}}
*[[Ulnar Gutter Splint]]
 
**Any rotational deformity should be fixed to allow proper hand function.
===Acute Reduction===
**10 degrees of angulation is tolerated in the 1st and 2nd metacarpals, while the third and fourth metacarpals can tolerate up to 40 degrees of angulation.
''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 goals}}
===Immobilization===
''See Diagnosis section for definition''
*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>
***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:
**[[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==
*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==
==See Also==
*[[Non-thumb metacarpal fractures]]
*[[Non-thumb metacarpal fractures]]
*[[Hand and finger fractures]]
==References==
<references/>


[[Category:Ortho]]
[[Category:Orthopedics]]

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

Boxer's Fracture (4th metacarpal)
Boxer's Fracture (5th metacarpal)

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 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
    • Buddy taping[1]
      • Similar functional outcomes those randomized to plaster cast with earlier return to work [2]
      • Similar satisfaction and pain control as those randomized to plaster casting [3]
      • Shorter ER Stay [4]
  • Complicated:

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

  1. ↑ 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
  2. ↑ 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
  3. ↑ 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
  4. ↑ 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
  5. ↑ 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.
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