March 08, 2019

Episode 158.0 – Boxer’s Fracture

5 minutes

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

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Boxer_s_Fracture_eq.m4a

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Tags: Orthopedics, Trauma

Podcast Video

https://youtu.be/UreET5eLHas

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

“20, 30, 40” rule

If angulation is more than:

20 in the middle finger metacarpal

30 in the ring finger metacarpal

40 in the pinky finger metacarpal

Analgesia with a hematoma block or ulnar nerve block

Reduction technique: https://www.aliem.com/2013/01/trick-of-trade-reducing-metacarpal/

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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