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Boxer Fracture

Topic updated on 11/13/17 6:15pm

Snapshot
  • An 18-year-old man presents to the emergency department with a swollen right hand. He punched a wall after having an argument. On physical exam, there is marked swelling over the ulnar side of his right hand with limited movement of the 5th metacarpophalangeal joint due to pain. Radiographs reveal a fracture of the 5th metacarpal neck of the right hand.
Introduction
  • Clinical definition
    • a 5th metacarpal neck fracture
  • Epidemiology
    • incidence
      • accounts for ~10% of all hand fractures
    • prevalence
      • more commonly seen in men
  • Pathogenesis
    • direct trauma to a closed fist against a hard surface (e.g., wall) results in fracture of the 5th metacarpal neck 
  • Prognosis
    • typically patients have good long-term function with appropriate management
Presentation
  • Symptoms
    • pain on the dorsum of the 5th metacarpal portion of the hand
  • Physical exam
    • tenderness to palpation over the affected metacarpal neck
      • as well as on the palmar surface of the hand
        • ecchymosis could be seen in this area
    • dorsal angulation of the fracture apex
    • swelling of the dorsum of the hand
Imaging
  • Radiography
    • indication
      • initial imaging test to establish the diagnosis and assess the degree of fracture angulation
        • certain clinicians may use an ultrasound initially
    • modalities
      • anteroposterior (AP) view
      • lateral view
      • oblique view
Studies
  • Making the diagnosis
    • based on imaging studies and clinical presentation
Differential
  • Hand contusion
    • distinguishing factor
      • typically secondary to a direct blow to the hand when the fist is closed instead of trauma 
      • on physical exam, there will not be a step-off that would be seen in a fracture
  • Metacarpal-phalangeal dislocation
    • distinguishing factor
      • mechanism of injury is usually secondary to a pulling or twisting of the phalanx
      • between the articulation of the distal metacarpal and proximal phalanx there is a loss of congruity
Treatment
  • Non-operative
    • splinting
      • indication
        • typically the initial method of immobilization or definitive treatment
    • closed reduction
      • indication
        • performed in patients with pseudo-clawing (metacarpophalangeal joint hyperextension and proximal interphalangeal joint flexion)
        • in cases of significant angulation of the 5th metacarpal fracture
  • Operative
    • surgical intervention
      • indication
        • performed in cases of open metacarpal neck fractures, neurovascular impairment, and fractures that cannot be managed nonoperatively
Complications
  • Joint stiffness (most common)


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