A Boxer’s Fracture is a common injury defined as a break in the neck of the fifth metacarpal bone, the long bone connecting the wrist to the little finger knuckle. This fracture often occurs when a person strikes a hard object with a closed fist, causing the head of the bone to displace toward the palm of the hand. The severity of the injury, particularly the degree to which the bone fragments are displaced or angled, dictates the necessary treatment approach. Understanding the medical process, from initial assessment to final rehabilitation, provides a clear path for recovery from this frequent hand trauma.
Recognizing the Injury and Initial Assessment
Immediate care for a potential hand fracture involves the RICE protocol: Rest, Ice, Compression, and Elevation. Applying ice for 15-20 minutes and elevating the hand above the heart help control swelling and pain before seeking medical attention.
Symptoms include localized pain and tenderness over the fifth knuckle and the back of the hand. Swelling and bruising are nearly always present, and the knuckle may appear visibly depressed or “lost” when the patient attempts to make a fist. A physical examination checks for rotational deformity, which occurs when the little finger crosses over or under the ring finger when making a fist.
Definitive diagnosis relies on X-rays, typically involving anterior-posterior, lateral, and oblique views of the hand. These images allow the physician to measure two parameters: the degree of angulation and the presence of any rotational misalignment. The measurements determine the necessity of intervention, as treatment depends on the stability and position of the fractured bone fragments.
Standard Non-Surgical Treatment
Most Boxer’s Fractures are stable enough to be managed without surgery, especially if angulation is acceptable and no rotational deformity is present. The primary non-surgical approach is closed reduction, where the physician manually realigns the fractured bone fragments by manipulating the finger while the patient is under anesthesia or sedation, followed by immobilization.
Once reduced, the hand is secured in an ulnar gutter splint or cast, immobilizing the wrist, hand, and the ring and little fingers. The fingers are placed in the “intrinsic plus” position, with the metacarpophalangeal (MCP) joints flexed to 70-90 degrees. This position prevents the collateral ligaments of the MCP joints from shortening, which can lead to permanent stiffness.
The typical duration for immobilization ranges from three to four weeks, allowing the initial bony healing to occur. During this period, the patient must keep the splint dry and clean, and gentle movement of the uninvolved fingers is encouraged to maintain mobility. Follow-up X-rays are routinely taken within the first week after the reduction to ensure the bone fragments have not shifted.
Determining the Need for Surgery
The decision for surgery is based on measurable thresholds seen on X-rays. The most common criterion is unacceptable angulation, the degree of forward bend in the bone shaft. Although the fifth metacarpal tolerates more angulation than other fingers, angulation beyond 30 to 45 degrees is often considered unstable or likely to cause functional problems.
Excessive angulation may result in a prominent bump on the palm, causing pain when gripping objects. The other major surgical indicator is rotational deformity, where the little finger twists out of alignment. Even slight rotation leads to significant functional impairment, causing the finger to overlap its neighbor when making a fist.
If a fracture cannot be successfully held in position after closed reduction, it is deemed unstable, justifying surgery. Open fractures, where the bone breaks through the skin, or fractures involving multiple metacarpals almost always require a surgical approach. The goal of surgery is to achieve anatomical alignment that cannot be maintained through casting.
Surgical Options and Rehabilitation
When surgery is necessary, several methods stabilize the broken fifth metacarpal bone. The most common technique is Closed Reduction and Percutaneous Pinning, which involves guiding thin metal wires (K-wires) through the skin to hold the bone fragments in place. This minimally invasive procedure uses specialized imaging during the operation to confirm proper alignment before the wires are cut flush with the skin.
For more complex or highly unstable fractures, the surgeon may perform Open Reduction Internal Fixation (ORIF). This procedure requires an incision to visualize the fracture, allowing for precise realignment before using small plates and screws to secure the bone fragments. After fixation, the hand is immobilized, though internal fixation provides more immediate stability.
Once immobilization is complete, the patient transitions to the recovery phase. Physical therapy is necessary to restore function, as the hand and finger joints will be stiff. The rehabilitation program focuses on exercises to regain full range of motion, improve grip strength, and restore dexterity. Full recovery and return to normal activities typically occur within six to twelve weeks, depending on the fracture’s severity and adherence to the therapy plan.