Ortho Hors D'oeuvres (Answer):

To review, this is a 23 year-old male presenting with hand pain after punching a wall.

Questions and Answers:

1) What is the key finding on x-ray? What is its eponym?

There is a fracture of the distal aspect (the neck) of the 5th metacarpal. This fracture does not involve the joint or the midshaft of the metacarpal. This fracture is known as a boxer’s fracture.

2) What are important physical exam findings?

As in every fracture, wounds suggesting open fracture must be identified; wounds over the MCP joint with this fracture likely indicate open fracture and require immediate operative washout and repair, with IV antibiotics within the first hour. For fractures that are closed, malrotation must be assessed for. Assess malrotation (scissoring) by flexing fingers in their normal cascade.

Finally, dorsal wounds can affect the dorsal sensory branch of the radial/ulnar nerves and volar wounds can involve digital nerves, so normal two-point discrimination and distal motor function should be evaluated.

3) What are the next steps in management?

Default management should be ulnar gutter placement with the wrist in 20 degrees of extension and the metacarpophalangeal joint flexed at 90 degrees.However, treatment can range from buddy taping to ulnar gutter placement to operative management depending on fracture angulation and an orthopedic follow-up should be arranged within the next week to discuss possible operative fixation or buddy taping. Below is the general acceptable degree of head angulation for each metacarpal (note more angulation is tolerated moving from index to little finger).

References:

Haughton DN, Jordan D, and Khan W. "Principles of Hand Fracture Management." Open Orthopedics Journal 6 (2012): 43-53.

Davenport M, Sotereanos D. “Injuries to the Hand and Digits” In: Tintinalli JE et al. Tintinalli Emergency Medicine 6th ed. New York: McGraw-Hill;2—4:1709-1730.

Thanks to Eric Silman for the plain film!

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