Boxer's fracture

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

• Non-thumb metacarpal fractures
  • Head
  • Neck
  • Shaft
  • Base
  • Boxer's fracture
• Thumb fracture
• Finger (Phalanx) Fracture
  • Proximal
  • Middle
  • Distal

Evaluation

Boxer's Fracture

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

Indications for 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

Splinting and Imobilization

• Splinting
  • Classically the Ulnar Gutter Splint has been recommended
  • Forearm volar splint with extension over the head of the MCP joint provides equal effect and is better tolerated
• Buddy taping
  • 2019 Annals of EM suggested no statistical difference in certain outcomes between plaster and buddy tape.
  • Per paper, applicable when pt 18-70 years old without open, intraarticular, or comminuted fracture, and angulation < 70 degrees.

Disposition

• Outpatient management

See Also

• Non-thumb metacarpal fractures
• Hand and finger fractures