What is your diagnosis?

Fifth metacarpal neck fracture, AKA “Boxer’s fracture”

• Pearl: Metacarpal fractures account for approximately 40% of all hand injuries, with the metacarpal neck being the most common. 

• Pearl: A boxer’s fracture is specifically a fracture of the distal 5th metacarpal, caused by an axial load injury - often from punching a person or object. 

Does this need urgent orthopedics consultation?

Examine range of motion, strength, and sensation. If the fracture is uncomplicated, closed, minimal displacement/angulation, and no evidence of neurovascular injury, then the fracture can be managed within the ED with outpatient orthopedics follow up. If the fracture is complex, particularly if an open fracture is present, orthopedics should be involved for potential surgical planning. 

• Pearl: Fracture angulation of up to 40 degrees can be allowed for boxer’s fractures. Greater than 40 degrees should be reduced, and greater than 60 degrees likely needs surgical fixation.  

What is your management in the ED?

An uncomplicated fracture can be managed with initial immobilization in the ED. Classically, this has been done using an ulnar gutter splint or with buddy taping.

• Pearl: There has been a reported higher degree of patient satisfaction and reduced need for follow up with buddy taping compared to splinting [1]. In addition, this is often associated with shorter ED stays as well. 

• Pearl: Fractures of the 4th metacarpal neck can be managed very similarly to this. However, fractures of the 2nd and 3rd metacarpals often require internal fixation [2]. 

What maneuver could you do to assist with acute pain management?

Ulnar nerve block

Image 2. Case courtesy of Herman Sehmbi [3], taken from pubmed.ncbi.nlm.nih.gov  

An ulnar nerve block can be done using ultrasound guidance, with injection of local anesthetic around the ulnar nerve bundle. Once done, this can potentially allow for any manipulation or splinting in the ED with minimal additional pain control. 

What additional management should be done for associated open wounds?

Antibiotics and orthopedics consultation as noted above- due to the higher likelihood of the injury resulting from contact with another person’s mouth, coverage for oral microbes should be done, likely with Amoxicillin-Clavulanate. 

• Pearl: An open wound or skin breakdown on the dorsal surface of the hand in the setting of a Boxer’s fracture should raise suspicion for a possible “fight bite”. This usually occurs from a person striking another person’s teeth/mouth during a fight. If not properly treated, this can turn into a closed fist infection, potentially requiring surgical washout and IV antibiotics.