Review of Boxer’s Fracture
Boxer’s fractures make up 20% of hand fractures (2). A boxer’s fracture is a fracture of the fifth metacarpal neck (3). The fracture is typically the result of the compression force through the fifth metacarpal neck when the hand is in a fist position (3). Fractures of the fifth metacarpal neck are actually less commonly seen in experienced boxers (4). More experienced boxers load the index finger when punching (4).
The evaluation of the hand on physical exam first requires providers to inspect the hand for soft tissue swelling, pain, and for any open fracture (4). Physical exam needs to evaluate for shortening, rotation, and angulation of the metacarpals (4). The fifth metacarpal is more likely to experience shortening due to less soft tissue support (4). A neurovascular exam also needs to be performed evaluating the phalange distal to the injury (8).
Diagnosis can typically be made with three standard views of the hand (1). There is debate as to what type of xray and measurement providers should use to determine the amount of fracture angulation. A study published in 2005 in the Journal of Orthopaedic Research evaluated plain radiographs to see which view had the most reliability and validity for measuring angulation. They found that measuring angulation with the lateral view had the most validity (6).
A CT scan of the hand can be performed to evaluate severely comminuted fracture or intraarticular fractures (1).
The goal of boxer’s fracture treatment is to have recovery of preinjury function by restoring the alignment and stabilization of the bone (1). Most patients are treated conservatively and do not require surgery. The typical angulation of the fracture accepted as the upper limit of normal is 30 degrees (2). Further angulation could lead to a decrease in MCP range of motion and weaken grip initiation (2). There is a lot of debate regarding the type immobilization necessary for a boxer’s fracture.
A study published in the Archives of Orthopaedic Trauma Surgery compared a soft wrap with buddy taping to closed reduction and cast immobilization. What they found was that four months after the fracture, neither group had a statistical difference in their pain score, range of motion, or quickDASH score (2). The group in the soft wrap group did not a show significant change in fracture angulation at four months (2).
Another study looked at plaster ulnar gutter cast vs. taping for four weeks following a boxer’s fracture. The ulnar gutter cast aimed to keep the MCPs flexed to 90 degrees (7). They found that those patients in the tape group had quicker functional recovery compared to the cast group (7). In addition, fractures that were reduced lost their reduction whether they were taped or placed in a cast (7).
Clinical stability of a metacarpal fracture typically occurs before radiographic union (8). This is important because prolonged immobilization leads to hand stiffness (8). Fractures of the hand generally do not need more than 4 weeks of immobilization (8).
Despite being a common fracture, there is still debate regarding the treatment of boxer’s fractures. There is no universal consensus on immobilization vs. taping. The decision for surgery depends on rotation, angulation, and shortening. Typically, fractures with more than 30 degrees of angulation are referred to hand surgery for evaluation.
By Gregory Rubin, DO
1) Taghinia, Amir H., and Simon G. Talbot. “Phalangeal and Metacarpal Fractures.” Clinics in Plastic Surgery, vol. 46, no. 3, July 2019, pp. 415–23. PubMed, https://doi.org/10.1016/j.cps.2019.02.011.
2) van Aaken, Jan, et al. “Fifth Metacarpal Neck Fractures Treated with Soft Wrap/Buddy Taping Compared to Reduction and Casting: Results of a Prospective, Multicenter, Randomized Trial.” Archives of Orthopaedic and Trauma Surgery, vol. 136, no. 1, Jan. 2016, pp. 135–42. PubMed, https://doi.org/10.1007/s00402-015-2361-0.
3) Hofmeister, Eric P., et al. “Comparison of 2 Methods of Immobilization of Fifth Metacarpal Neck Fractures: A Prospective Randomized Study.” The Journal of Hand Surgery, vol. 33, no. 8, Oct. 2008, pp. 1362–68. PubMed, https://doi.org/10.1016/j.jhsa.2008.04.010.
4) Cotterell, Ilvy H., and Marc J. Richard. “Metacarpal and Phalangeal Fractures in Athletes.” Clinics in Sports Medicine, vol. 34, no. 1, Jan. 2015, pp. 69–98. PubMed, https://doi.org/10.1016/j.csm.2014.09.009.
5) Beredjiklian, Pedro K. “Small Finger Metacarpal Neck Fractures.” The Journal of Hand Surgery, vol. 34, no. 8, Oct. 2009, pp. 1524–26. PubMed, https://doi.org/10.1016/j.jhsa.2009.06.015.
6) Lamraski, G., et al. “Reliability and Validity of Plain Radiographs to Assess Angulation of Small Finger Metacarpal Neck Fractures: Human Cadaveric Study.” Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society, vol. 24, no. 1, Jan. 2006, pp. 37–45. PubMed, https://doi.org/10.1002/jor.20025.
7) Braakman, M., et al. “Functional Taping of Fractures of the 5th Metacarpal Results in a Quicker Recovery.” Injury, vol. 29, no. 1, Jan. 1998, pp. 5–9. PubMed, https://doi.org/10.1016/s0020-1383(97)00106-x.
8) Meals, Clifton, and Roy Meals. “Hand Fractures: A Review of Current Treatment Strategies.” The Journal of Hand Surgery, vol. 38, no. 5, May 2013, pp. 1021–31; quiz 1031. PubMed, https://doi.org/10.1016/j.jhsa.2013.02.017.