A Boxer’s fracture is a common break in the hand, defined as a fracture of the neck of the metacarpal bone. This injury most frequently affects the fifth metacarpal, the long bone connecting the wrist to the pinky finger’s knuckle. The injury typically results from an axial load, such as punching a hard object with a clenched fist, which is how the fracture earned its name. Medical assessment is necessary to prevent long-term complications that could affect hand function.
Recognizing the Injury
The immediate signs of a Boxer’s fracture include sharp, localized pain directly over the knuckle of the affected finger, often accompanied by a distinct snapping or popping sensation at the time of impact. Swelling develops rapidly and bruising appears on the back of the hand. A tell-tale sign is a visibly flattened or sunken knuckle, indicating the metacarpal head has shifted toward the palm.
The most concerning sign is a rotational deformity of the finger, which becomes apparent when the patient attempts to make a fist. The injured pinky finger may overlap or cross beneath the adjacent ring finger, indicating that the bone fragments are misaligned. Any difficulty in moving the hand or finger, or a noticeable misalignment, requires prompt medical evaluation.
Immediate First Aid Measures
Before seeking professional medical care, patients should immediately apply the principles of Rest, Ice, Compression, and Elevation (R.I.C.E.) to manage pain and limit swelling. The injured hand should be kept still and elevated above the level of the heart to help drain excess fluid from the area. Applying a cold compress or ice pack wrapped in a towel to the back of the hand for short intervals can help reduce inflammation.
Compression can be applied using a soft bandage, but it should not be wrapped tightly enough to cause numbness or discoloration in the fingers. Stabilize the hand gently in a comfortable position, but avoid attempting to manually straighten or “set” the bone themselves. Over-the-counter pain relievers such as acetaminophen or ibuprofen can be taken to manage discomfort until a healthcare provider is seen.
Professional Treatment Options
Treatment for a Boxer’s fracture depends on the results of an X-ray, which determines the fracture’s location, degree of angulation, and rotational deformity. Fractures with minimal displacement or angulation are typically managed non-surgically through immobilization. The fifth metacarpal can tolerate a significant degree of dorsal angulation, sometimes up to 70 degrees, without causing functional impairment.
For fractures with unacceptable angulation or shortening, a physician performs a closed reduction, manually manipulating the hand to realign the bone fragments. Following a successful reduction, the hand is immobilized using a specialized splint, most commonly the ulnar gutter splint. This splint holds the wrist in slight extension and flexes the metacarpophalangeal (MCP) joints—the knuckles—to between 70 and 90 degrees, a position often called the “safe position.”
Maintaining the knuckles in this safe position prevents the collateral ligaments from shortening, a common complication that leads to permanent stiffness. The splint is usually worn for a period of three to six weeks, with follow-up X-rays taken to confirm that the fracture alignment is maintained during healing. Surgery is reserved for severe cases, such as open fractures, significant rotational deformity, or those where closed reduction fails to achieve stability.
Surgical intervention, often called Open Reduction Internal Fixation (ORIF), may involve the use of pins, wires, or small plates and screws to stabilize the fracture fragments. The choice between non-operative and operative management is complex, but both methods often lead to comparable long-term functional outcomes. The main goal of surgery is to correct severe rotational malalignment, which can cause the finger to scissor over its neighbor when making a fist.
Recovery and Physical Therapy
Once the immobilization period is complete and the fracture shows signs of healing, the focus shifts to restoring full hand function. A common issue after immobilization is joint stiffness, particularly in the MCP joints, due to prolonged rest. Patients also experience reduced grip strength and persistent swelling.
Hand therapy, often with a physical therapist, addresses these impairments. The initial focus is on gentle, active range-of-motion exercises to regain full flexibility in the fingers and wrist. Strengthening exercises are introduced to rebuild grip and pinch strength. Full recovery typically occurs within six to twelve weeks post-injury.