The Case
A surly 16 year old young man punched a locker after learning that he would get an A minus on his Biology test. Of course he punched it with his dominant right hand. Now he is concerned about two things: One, that he won’t get into the Ivy League school of his choice and Two, that he hurt his hand. On exam you note that he has significant swelling of the ulnar aspect of his right hand.
From lifeinthefastlane.com
Because you think he hurt a bone you get an X-Ray. It shows the following…
The X-Ray you ordered
Diagnosis
If you weren’t already suspecting it based on the exam the X-Ray makes it clear that this young man has a fracture of the right 5th metacarpal – AKA a Boxer’s fracture. It occurs when a patient (let’s face it, a male patient) punches something.
Management
The management differs primarily based on the degree of angulation. Obviously you want to assess the patient’s neurovascular status – fortunately vascular and nerve injuries are rare in Boxer’s Fractures. It is also important to examine the digit in extension and flexion to assure that there is no rotational deformity.
Ideally a 3-view (AP, lateral and oblique) series of X-Rays allows you to assess for angulation and rotation more completely. Any fracture with rotational deformity should be reduced. For tolerant patients this can be accomplished at the bedside with adequate analgesia and a hematoma block and/or procedural sedation. In my experience a hematoma block is sufficient for many adolescents. In fractures with non-rotational deformity the degree of angulation can serve as a general guide for when reduction is necessary.
- 2nd metacarpal – 10 degrees
- 3rd metacarpal – 20 degrees
- 4th metacarpal – 30 degrees
- 5th metacarpal – 40 degrees
Whether or not you need to reduce early immobilization is important. Commercially available, fiberglass or plaster splints are all appropriate. You can do a volar splint to the palmar crease or an ulnar gutter splint. The wrist should be at 30 degrees with the MCP is at 90. Leave the PIP and DIP joints unsplinted! It is not necessary to immobilize them and leads to good outcomes (and higher patient satisfaction especially for students). Check out this video for a nice example of management in the ED.
