What is the diagnosis?

This is a fracture of the fifth metacarpal neck, commonly referred to as a boxer’s fracture. 

• Pearl: A fracture of the fourth metacarpal neck can be referred to as a boxer’s fracture as well.

What is the mechanism of injury?

This injury is from a direct axial load to the fist, often by punching something, hence the common name of boxers fracture.

What physical exam findings are expected?

The patient usually has swollen lateral aspects of hands with acute tenderness along the fourth/fifth metacarpal. Be sure to: 

• Assess neurovascular status

• In particular ensure that ulnar nerve is intact. 

• Always looks for signs of teeth marks or evidence of lacerations as this would become an open fracture/fight bite

• Ensure to check for snuff box tenderness as well

• If the wound is open ensure that extensor and flexor tendons are intact

• Always look for signs of other injuries and assess for possible intoxications

Which imaging modalities can be used?

As with many orthopedic injuries, an XR is the best choice for imaging. Ensure to get a PA, lateral and oblique view of the hand.

What is the management in the ED?

Assess if the fracture is displaced. If angulation is greater than 30 degrees in the 4th metacarpal and and greater than 40 degrees in the fifth metacarpal, these require reduction [1]. Reduction can be done via the Jahss maneuver. This is done by having the patient attempt to recreate a fist to pull the metacarpal head in the correct position. Once in the correct position, fractures can be either splinted or buddy taped as this has been found to have similar results to splinting at 12 weeks [2]. If you were to splint these injuries it should be with an ulnar gutter splint. 

• Pearl: Wounds over the fracture should be treated as open fractures. Give antibiotics and do not close the wound.

When do you consult Orthopedics?

Orthopedics should be consulted whenever there is an open fracture as these likely need washouts. Irreducible fractures and any concern for neurovascular compromise also warrant a consult.