Updated: 11/10/2017

Boxer Fracture (Fifth Metacarpal Neck Fracture)

Review Topic
  • A 20-year-old man presents to the emergency department due to severe pain in his right hand. He reports that a few hours prior to presentation he was in an argument and due to his frustration he punched the wall with a closed fist. Since that event he developed 8/10 pain. On physical exam, there is swelling on the dorsum of the hand with tenderness to palpation on the dorsal metacarpal joint of the 5th digit of the right hand. There is also tenderness upon palpation on the volar surface of that region with evidence of ecchymosis. Neurovascular status of the hand is intact. A radiograph of the hand is shown. 

  • 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
  • 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
  • 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
  • Making the diagnosis
    • based on imaging studies and clinical presentation
  • 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
  • Non-operative
    • splinting
      • indication
        • typically the initial method of immobilization or definitive treatment
    • closed reduction
      • indication
        • performed in patients with pseudo-clawing (MCP joint hyperextension and PIP 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 non-operatively
  • Joint stiffness (most common)

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