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