BOXER’S FRACTURE Overview: A boxer’s fracture is defined as a break through the bones of the hand that form the knuckles. Some doctors use the term “brawler’s fracture” rather than “boxer’s fracture” because a boxer is not likely to get this injury. The less well-trained brawlers have to learn how to punch without hurting themselves. The metacarpal bones in the hand connect the bones in the fingers to the bones in the wrist. The head of the metacarpal bones form the knuckle of an enclosed fist. A boxer’s fracture involves a break in the neck of the metacarpal. This was described originally in the fracture of the metacarpal bone of the little (small) finger because this is the most common one to break when punching an immovable object. Boxer’s fractures occur in the metacarpal bones that connect the ring finger or the little finger to the wrist. These are known as the fourth and fifth metacarpal bones. Some doctors include breaks in the neck of the second and third metacarpal bones in the definition of a boxer’s fracture. The second metacarpal bone connects the index finger to the wrist, and the third metacarpal connects the middle finger to the wrist. Causes: Boxer’s fractures receive their name from one of the most common causes – punching an object with a closed fist. This occurs commonly during fist fights or from punching a hard object such as a wall. Although these breaks usually occur when the hand is closed into a fist, they can also occur when the hand is not clenched and strikes a hard object. Symptoms: The typical symptoms of a boxer’s fracture are pain or tenderness centered in a spe- cific location on the hand corresponding to one of the metacarpal bones, around the knuckle. You may also note pain with movement of your hand or fingers. • When a bone is broken, you may experience a snapping or popping sensation in the affected bone. • Your hand may swell, discolor, or bruise around the injury site. Deformity of the bro- ken bone or knuckle may also be noted. There may also be abnormal movement of the broken bone fragments. The doctor may be able to produce pain by pressing on the broken bone. In addition, pain can be produced by grabbing the finger that at- taches to the metacarpal bone that was hurt and pushing it inward toward the bro- ken bone. • If you make a fist with the affected hand, the doctor may notice misalignment of the associated finger - a deformity of the broken bone. When making a fist, the finger involved may bend toward the thumb more than usual. This is known as rotation, and though not always seen, its presence may indicate the possibility of a more se- rious type of boxer’s fracture. • Another common sign of a possible boxer’s fracture is a cut on the hand. A cut in the skin associated with a boxer’s fracture may indicate a more serious type of boxer’s fracture. When to seek medical care: Any time you have an injury and a fracture is suspected, contact your doctor for in- structions. If the doctor is unavailable, go to the emergency department for evaluation. Also contact your doctor or go to the emergency department if you have been splinted or casted and develop increasing pain, numbness, or tingling in the fingers of the casted arm. Any signs of infection from a cut or stitched wound also require evaluation by a doctor. Any hand injury that has signs or symptoms suggesting a fracture should be evaluated by a doctor. This may be accomplished by contacting your doctor. If your doctor can’t see you right away, you may go to a hospital’s emergency department. Exams & Tests: Physical examination in conjunction with X-rays is essential to properly diagnose a boxer’s fracture. Findings that suggested the need for X-rays include activities that in- crease the risk of fracture, deformity of the hand, localized tenderness, swelling of the hand, discoloration, decreased ability to move the hand, wrist or fingers, numbness, unequal temperatures between the injured and uninjured hands, or a cut caused by teeth when punching someone in the mouth (resulting in a human bite injury). • The doctor will determine if X-rays are warranted based on the circumstances sur- rounding the injury. After the doctor obtains detailed information about how the hand was injured, a physical examination is the next step in the evaluation. ο Swelling and discoloration commonly are seen with fractures and are associated with damage caused by direct trauma to the bone and surrounding muscles, ligaments, tendons, nerves, and blood vessels. ο Decreased ability to move the hand in the usual directions and manner may re- sult from the swelling or pain associated with the fracture. The doctor will ask you to make a fist. This helps to determine the extent of the injury as well as the type of treatment that may be needed. This also may indicate if a ligament has been torn. Torn ligaments will not show up on standard X-rays, but they some- times occur with fractures. • X-rays of the hand are performed to look at the hand from three different directions. Evaluating the hand from different viewpoints reduces the risk of not seeing a frac- ture on the X-ray. After evaluating the bones on the X-ray, the doctor can determine what type of fracture is present. In certain cases, the doctor may order more X-rays, with special views to look for hard-to-find fractures. These studies are ordered when the standard X-rays do not show a fracture and the information regarding your injury or physical examination suggests the presence of a hard-to-find fracture. • On physical examination the doctor will look for the presence of foreign bodies in the hand. Activities that could cause a foreign body to become lodged in the hand are these: punching another person in the mouth, being bitten by an animal, being cut with a sharp object, a penetrating injury, or abrasions or splinters from an ob- ject. Foreign bodies that may show up on X-rays are glass, bone, metal, and stones. However, organic or living materials such as wood or plants will not show up on standard X-rays and will require further studies if their presence is suspected. Self-care treatment at home: Home care for a boxer’s fractures can be divided into care prior to seeing a doctor and care after a diagnosis of a boxer’s fracture is made. • The immediate goals of caring for an injured hand are to minimize pain and swell- ing, minimize the risk of infection of any open cuts, and to prevent injury caused by an unstable fracture. ο The best approach to reduce pain and swelling is to apply an ice pack to the in- jured area. If ice is not available, placing a towel soaked in cold water on the in- jured hand will work. Elevating the injured hand will also help reduce swelling. ο An open cut sustained at the time of injury suggests an open fracture – a type of broken bone that is at increased risk for infection and poor healing. All cuts should be washed with soap and water and then covered with a clean bandage immediately to reduce the risk of infection. ο A key technique to prevent further injury from a fracture is to immobilize the in- jured hand. This is often best accomplished by holding the injured hand in the uninjured hand. In addition, take care not to use the injured hand to lift objects or perform any task that would place stress on it. Using a broken hand that is not properly immobilized can cause damage to surrounding muscles, blood ves- sels, tendons, ligaments, and nerves. • Home care after the diagnosis of boxer’s fracture is based on how the doctor treated the hand. Home care includes pain management, cast or splint care, and monitoring for signs of infection. ο Bones, like many other parts of the body, contain nerve fibers that transmit the sensation of pain. Pain from broken bones is caused by swelling due to injury of the tissues around the fracture site, or by the broken bone moving against the nerve fibers. Pain should lessen once a broken bone is immobilized and move- ment is prevented. Some degree of pain may still persist. When a doctor writes a prescription for pain medication, it is important to take the medication as pre- scribed. This will alleviate pain and will minimize the risk of any unwanted side effects from the medication. For mild pain, over-the-counter (OTC) medications like acetaminophen (Tylenol) or ibuprofen (Advil) may be used as directed on the label. This should be discussed with the doctor before you take these medi- cines. ο Splinting or casting commonly is performed on all boxer’s fractures that do not require immediate surgery. All splints and casts should be kept dry in order to maintain there strength. A complication that can be seen with this procedure is the cast becoming too tight from the swelling of the fracture. When this hap- pens, you may feel pain under the cast or splint. Another sign is numbness or tingling in the fingers on the casted hand. In addition, the finger may become cool to the touch. When this occurs, call your doctor or report to a hospital’s emergency department immediately for evaluation. ο Infection can occur at any open cut. Wounds should be kept clean and covered until healing is complete. If stitches are used to close a cut, the doctor will pro- vide additional instructions on how to care for the stitches and when they should be removed. It is important to follow these directions carefully to minimize the risk of infection. Monitor any cuts for signs of infection. Warning signs of infec- tion include redness, red streaking away from the cut, warmth, or swelling around the site of the cut. Pus may also drain from the wound. Any of these signs requires immediate attention. Medical treatment: If a boxer’s fracture is detected, the primary goals of treatment are to immobilize the hand to permit proper healing and to alleviate the pain associated with fractures. In order to properly immobilize most broken bones, the splint should immobilize the joints above and below the site of injury. In the case of a boxer’s fracture, different types of splints may be used. One type of splint may extend from the fingers, with the fingertips exposed, to the forearm near the elbow. Another type of splint that has been shown to be effective for some boxer’s fractures of the little finger is to buddy-tape the ring finger and the little finger together. Your doctor will decide what type of splint will treat your fracture the best. • When a boxer’s fracture occurs, it is possible for a portion of the metacarpal bone to move out of normal alignment. This is called angulation. The amount of angula- tion will determine what type of treatment is required to ensure proper healing. Peo- ple with boxer’s fractures who have acceptable amounts of angulation may be splinted in the emergency department or doctor’s office. • Any degree of angulation in the second or third metacarpal bones is considered ab- normal and requires referral to a hand specialist for possible surgical repair. Boxer’s fractures of the fourth and fifth metacarpal bones only require surgery if large de- grees of angulation are present and the bones cannot be moved into the correct place by pulling and pushing on them. • Because broken bones can cause significant amounts of pain, pain management is an important aspect to treating broken bones. Pain management is best accom- plished with anti-inflammatory medicines and pain relievers. Acetaminophen (Tylenol) or ibuprofen (Advil) usually provides good pain relief with few side effects. These over-the-counter (OTC) medications, or any prescription pain medicines, should be taken as directed to decrease the risk of side effects. Follow-up: A person with a boxer’s fracture frequently is advised to follow-up with a bone special- ist (orthopaedic surgeon) or a hand specialist to ensure that the broken bone mends properly. The hand specialist may be either an orthopaedic surgeon or a plastic sur- geon who specializes in hand injuries. • Follow-up should occur within one week of the initial injury if there is not a critical amount of angulation. If angulation of the fracture exceeds acceptable levels, fol- low-up should occur sooner. • If a plaster splint is used and you develop increased pain or numbness in your fin- gers, or if your fingers become cold and blue, then notify your doctor. Prevention: The key to preventing a boxer’s fracture is to avoid situations in which the injury can occur. Boxer’s fractures most commonly occur during fist fights and when someone punches a hard object in anger or frustration. Avoiding these situations can reduce sig- nificantly the risk of sustaining a boxer’s fracture. In addition, decreasing the loss of bone that occurs naturally with age also is critical. This can be accomplished with regu- lar exercise and calcium supplements or adequate intake of dairy products. Outlook: With proper immobilization of the broken bones and good follow-up with a hand spe- cialist, most people with a boxer’s fracture have a good prognosis. Those who require surgery often have a longer period of recovery than people who only require splinting. Some will require physical therapy after the splint is removed because the muscles be- come weakened from not being used.