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 Download Leave a Comment Tags: Orthopedics, Trauma 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: