Episode 158.0 – Boxer’s Fracture - a podcast by Core EM

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







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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

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