A 25 year-old male presents with swelling and pain to the hand. He just had a temper tantrum at home and punched his wall.
You examine his hand and find significant point tenderness and swelling over the 5th metacarpal bone of his right hand. The neurovascular exam is unremarkable.
You obtain the following plain films:
What is the diagnosis and what is your management?
This is a 5th metacarpal neck fracture. These are common fractures, and if not treated appropriately can lead to significant hand dysfunction. Important features to note are degree of angulation, rotation, shortening, displacement and soft tissue swelling. The metacarpal can be divided into parts: head, neck, shaft and base.
Fracture of the metacarpal neck at the 5th metacarpal is also known as a Boxer’s fracture. Its angulation is typically apex dorsal. The dorsal apex angulation is a result of the force of impact at the 5th MCP joint being directed dorsally driving the distal fragment volarly, and the intrinsic hand muscles further applying a force volarly on the distal fracture fragment. The goal of management is to reduce and align fracture fragments to maintain function. A small degree of shortening can be tolerated much better than malrotation, as the latter can result in significant amounts of finger overlap during MCP joint flexion. Nondisplaced or minimally displaced fractures can be placed in an ulnar gutter splint. Displaced, angulated, and/or rotated distal fragments should undergo reduction attempts followed by placement in a splint and post-reduction films. To make the reduction procedure tolerable a local hematoma block or nerve block can be performed prior to reduction.
Browner, Bruce and Robert Fuller. Musculoskeletal Emergencies. Philadelphia: Elsevier Saunders, 2013. Print.
Also see this great post: http://lifeinthefastlane.com/minor-injuries-003/