Boxer Fracture Brace

[Jonathon Burnside]

Thisfracture is a stable injury. It's not likely for it to get worse. It's safely treated with the hand in a Velcro brace (Picture 2). The brace will be put on the hand to help keep the bone protected and the wrist and fingers still as the bone heals.

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Fractures of the fifth metacarpal neck, or boxer's fractures, are common, particularly among young men. Because of the high frequency of this injury, there is a considerable range of treatment options. The purpose of this systematic review was to determine whether reduction and splint or cast immobilization is necessary for fractures of the fifth metacarpal neck. The authors conducted a systematic review of all published studies that randomized these fractures to cast immobilization vs treatment with soft wrap without reduction. Cast immobilization is not superior to soft wrap without reduction in most cases. The study found that reduction and cast immobilization is not necessary for boxer's fractures. [Orthopedics. 2016; 39(3):188-192.].

Used to stabilize fractures to the 4th and/or 5th metacarpal (MC) bones, and also provides stabilization to the 4th and 5th interphalangeal and wrist joints. May be used for metacarpal (MC) head/neck fracture of the 4th and/or 5th metacarpal. Not made with natural rubber latex.

The ability to thermoform and custom fit the Brace to the patient's extremity ensures a comfortable fit.Dorsal hook-and-loop secure tab allows the practitioner to secure the over-lapping (top) portion of brace to better manage brace stability.Hook-and-loop fastener straps across the web space and around the 4th and 5th digits can be attached anywhere to the surface of the brace for better stability and greater comfort.Finger section can be trimmed (as directed by the physician) to accommodate desired range of motion.Boa Fit System allows for quick adjustment in circumferential compression and can be locked with BOA Locking Ring.

Metacarpal fractures are a prevalent concern, comprising 40% of all hand fractures. Particularly affecting an active and youthful demographic are 5th metacarpal fractures, also known as boxer's fractures. These injuries can impair grip strength and dexterity, which are essential for various daily activities and sports. Without proper treatment, boxer's fractures in the young are at risk for malunion or nonunion due to their active lifestyles. Chronic pain, weakness, and hand function limitations may result if the condition is not properly addressed. Nonoperative and operative treatments may be considered, depending on the fracture type and severity.

This activity for healthcare professionals is designed to enhance learners' competence in evaluating and managing 5th metacarpal fractures. Participants in this activity gain in-depth insights into the etiology, presentation, evaluation, and management of these injuries. Treatment strategies are meticulously explored, differentiating between open and closed fractures and considering factors such as angulation, shortening, and rotation. This activity also underscores the interprofessional healthcare team's pivotal role in improving patient outcomes and mitigating the potential economic impact of missed workdays.

Objectives:Identify the signs and symptoms indicative of a 5th metacarpal fracture.Determine critical diagnostic imaging studies when evaluating patients with a suspected 5th metacarpal fracture.Compare the treatment options available for 5th metacarpal fractures, including both conservative and surgical care.Improve interprofessional coordination and communication practices when formulating short- and long-term care plans for individuals with 5th metacarpal fractures.Access free multiple choice questions on this topic.

Metacarpal fractures account for 40% of all hand fractures.[1] Fifth metacarpal injuries account for 20% of all hand fractures and usually affect the young and active. Certain 5th metacarpal fracture patterns produce functional impairment, evident in declining 5th finger grip strength and 5th metacarpophalangeal (MCP) joint mobility.[2] Manual dexterity consequently diminishes, causing missed workdays and their economic implications.[3][4]

The metacarpus comprises the palm's skeleton, connecting the wrist bones (carpus) and phalanges. Each digit has a metacarpal bone, with the 1st metacarpal supporting the thumb and the 5th metacarpal assisting the little finger. Each metacarpal has a head, shaft, neck, and base. The heads articulate with the proximal phalanges distally, while the bases articulate with the carpus proximally. The neck is the narrowed portion of the metacarpal bone just distal to the base. This area is commonly involved in boxer's fractures.

The metacarpal bones form the palm's framework and provide attachment points for muscles responsible for hand movements and grip strength. Metacarpals 2 to 5 are closely attached. Consequently, isolated fractures are often stable. The palm's bones are also highly vascularized. Thus, metacarpal fractures heal rapidly except if crushed or severely displaced. Metacarpal injuries can significantly impair hand function, affecting daily living, work, and sports activities if not properly treated.

The incidence of metacarpal neck fractures presenting for hospital care in the United States is 13.6 per 100,000 person-years. Metacarpal fractures account for 40% of all hand fractures, while fractures of the 5th metacarpal neck account for 10%. The incidence in males is 5 times higher than in females.[8] Males aged 10 to 19 have the highest incidence, followed by males aged 20 to 29. Fifth metacarpal injuries commonly occur at home and athletic events.[9]

Axial load via direct trauma to a clenched fist transfers energy to the metacarpal bone, causing fractures most commonly at the 5th metacarpal's neck. The injury typically results in apical-dorsal angulation due partly to the forces exerted by the interosseous muscles' pull.[10]

The interosseous muscles, responsible for finger adduction and abduction, originate from the metacarpal shafts and insert into the proximal phalanges. The collateral ligaments join the metacarpal bones to the proximal phalanges and must be considered during splinting to minimize ligament shortening and consequent mobility loss. The ligaments are taut in flexion and slack in extension. Therefore, the MCP joints should be splinted in flexion to prevent shortening (intrinsic plus positioning).[11]

Patients with metacarpal fractures present with complaints of dorsal hand pain, swelling, and deformity in the setting of one of the mechanisms that may give rise to this injury. Patients may also report bruising and difficulty moving the ulnar-side digits.

Plain radiographs are the preferred imaging modality when evaluating suspected metacarpal fractures (see Image. Boxer's Fracture). Anteroposterior, lateral, and oblique views should be obtained. The lateral view should be used to measure the degree of angulation between the metacarpal shaft and the fracture fragment's midpoint.[16] The metacarpal head and neck normally form an angle of 15. Fracture angulation usually exceeds this value. The tangential radiographic projection helps identify occult radial head fractures. Brewerton's x-ray imaging technique is performed by placing the fingers flat on the x-ray plate, flexing the MCP joints at a 65 angle, and angulating the beam 15 toward the hand's ulnar side.[17]

Recent literature suggests that bedside ultrasound may also be used to diagnose a metacarpal fracture initially.[18] Computed tomography is generally not used for diagnosing metacarpal fractures. However, metacarpal head injuries and occult fractures in other bones may be detected by this modality in patients with negative plain radiographs but with clinical signs suspicious of a fracture.[19]

A closed boxer's fracture without angulation, malrotation, or displacement may be initially immobilized with splinting, often using an ulnar gutter splint. Alternatively, a premade Galveston splint or a custom orthosis may be used.[20]

Closed reduction is required for a boxer's fracture with angulation greater than 30. Analgesia options during the procedure include a hematoma and ulnar nerve block. Young children or patients with anxiety may require sedation. However, this procedure typically is tolerated well, even without sedation.

Closed reduction of a boxer's fracture is accomplished using the "90-90 method." The MCP, DIP, and PIP joints should all be flexed to 90. The clinician should then apply volar pressure over the dorsal aspect of the fracture site while applying pressure axially to the flexed PIP joint.[20] This axial pressure to the PIP applies dorsal force to the distal fracture fragment. The clinician should be able to feel the reduction when it has been achieved. The injury should be immobilized with an ulnar gutter splint. Postreduction films should be taken to assess reduction adequacy.[22] The 5th metacarpal neck can tolerate angulation up to 70. Nonoperative management can continue if the fracture remains within acceptable tolerances. The 5th metacarpal shaft's acceptable angulation is 30.[23]

Surgical referral is indicated for fractures that are open, severely comminuted, malrotated, or associated with neurovascular injury.[24] Surgical referral is also appropriate for cases of malunion, nonunion, and persistent angulation after conservative treatment. Surgical options include open reduction with internal fixation and closed reduction with percutaneous pinning.

Repeat radiographs must be obtained within a week to assess alignment. Radiographs should be obtained every 2 weeks afterward until clinical and radiographic healing are present, typically between 4 to 6 weeks. Even with adequate reduction, cosmetic deformity may arise due to loss of the normal knuckle contour. After a short immobilization period, passive and active range-of-motion exercises should alleviate MCP and PIP joint stiffness. Literature supports early mobilization rather than prolonged immobilization of these injuries.[25][26] Persistent functional loss after several weeks of physical therapy warrants occupational therapy.

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