Boxers Break Cast

[Heike Fallago]

Aboxer's fracture is 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 finger to the bones in the wrist. There are five metacarpal bones, one to connect each finger to the wrist. All of the metacarpal bones have the same anatomic structure. Each consists of the base, the shaft, the neck, and the head.

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.

The typical symptoms of a boxer's fracture are pain or tenderness centered in a specific location on the hand corresponding to one of the metacarpal bones, around the knuckle. The person may also note pain with movement of the hand or fingers.

Any time a person has an injury and a fracture are suspected, contact a doctor for instructions. If a doctor is unavailable, go to the emergency department for evaluation. Contact a doctor or go to the emergency department if the affected individual's hand or arm has been splinted or cast and they develop increasing pain, numbness, or tingling in the fingers on the cast or splinted arm. Any signs of infection from a cut or sutured 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 a doctor. If the affected individual cannot see a doctor immediately, go to a hospital's emergency department.

Physical examination in conjunction with X-rays is essential to properly diagnose a boxer's fracture. Findings that suggest the need for X-rays include activities that increase 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 surrounding the injury. After the doctor obtains detailed information about how the hand was injured, a physical examination is the next step in the evaluation.

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 fracture 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 the patient's injury or physical examination suggests the presence of a hard-to-find fracture.

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.

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 little finger together. The doctor will decide what type of splint will treat the patient's fracture the best.

A person with a boxer's fracture frequently is advised to follow-up with a bone specialist (orthopedic surgeon) or a hand specialist to ensure that the broken bone mends properly. The hand specialist may be either an orthopedic surgeon or a plastic surgeon who specializes in hand injuries.

With proper immobilization of the broken bones and good follow-up with a hand specialist, 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 become weakened from not being used.

The key to preventing boxer's fractures 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 significantly 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 regular exercise and calcium supplements or adequate intake of dairy products.

Management of a wide variety of musculoskeletal conditions requires the use of a cast or splint. Splints are noncircumferential immobilizers that accommodate swelling. This quality makes splints ideal for the management of a variety of acute musculoskeletal conditions in which swelling is anticipated, such as acute fractures or sprains, or for initial stabilization of reduced, displaced, or unstable fractures before orthopedic intervention. Casts are circumferential immobilizers. Because of this, casts provide superior immobilization but are less forgiving, have higher complication rates, and are generally reserved for complex and/or definitive fracture management. To maximize benefits while minimizing complications, the use of casts and splints is generally limited to the short term. Excessive immobilization from continuous use of a cast or splint can lead to chronic pain, joint stiffness, muscle atrophy, or more severe complications (e.g., complex regional pain syndrome). All patients who are placed in a splint or cast require careful monitoring to ensure proper recovery. Selection of a specific cast or splint varies based on the area of the body being treated, and on the acuity and stability of the injury. Indications and accurate application techniques vary for each type of splint and cast commonly encountered in a primary care setting. This article highlights the different types of splints and casts that are used in various circumstances and how each is applied.

Family physicians often make decisions about the use of splints and casts in the management of musculoskeletal disorders. Because of this, they need to be familiar with indications for application, proper technique, and the potential pitfalls of casting and splinting to optimize patient care when treating common orthopedic injuries.

Splints and casts immobilize musculoskeletal injuries while diminishing pain and promoting healing; however, they differ in their construction, indications, benefits, and risks. When determining whether to apply a splint or a cast, the physician must make an accurate diagnosis, as well as assess the stage, severity, and stability of the injury; the patient's functional requirements; and the risk of complications (Table 1).1,2

Because splints are noncircumferential immobilizers and are, therefore, more forgiving, they allow for swelling in the acute phase. Splinting is useful for a variety of acute orthopedic conditions such as fractures, reduced joint dislocations, sprains, severe soft tissue injuries, and post-laceration repairs. The purpose of splinting acutely is to immobilize and protect the injured extremity, aid in healing, and lessen pain. Splinting during the later phases of injury or for chronic conditions will assist with healing, long-term pain control, and progression of physical function, and it will slow progression of the pathologic process.3,4

Casting involves circumferential application of plaster or fiberglass to an extremity. Casts provide superior immobilization, but are less forgiving and have higher complication rates. Therefore, they are usually reserved for complex and/or definitive fracture management.

Application of any immobilizer comes with potential complications, including ischemia, heat injury, pressure sores, skin breakdown, infection, dermatitis, neurologic injury, and compartment syndrome. These conditions can occur regardless of how long the device is used.5 To maximize benefits while minimizing complications, the use of casts and splints is generally limited to the short term. Excessive immobilization from continuous use of a cast or splint can lead to chronic pain, joint stiffness, muscle atrophy, or more severe complications, such as complex regional pain syndrome.6 All patients who are placed in a splint or cast require careful monitoring to ensure proper recovery.7

This article highlights the different types of splints and casts that are used in various circumstances and how each is applied. In a previous article in American Family Physician, we discussed the principles and risks of casting and splinting, as well as proper techniques for safe application.6

Casting and splinting both begin by placing the injured extremity in its position of function. Casting continues with application of stockinette, then circumferential application of two or three layers of cotton padding, and finally circumferential application of plaster or fiber-glass. In general, 2-inch padding is used for the hands, 2- to 4-inch padding for the upper extremities, 3-inch padding for the feet, and 4- to 6-inch padding for the lower extremities.

Splinting may be accomplished in a variety of ways. One option is to begin as if creating a cast and, with the extremity in its position of function, apply stockinette, then a layer of overlapping circumferential cotton padding. The wet splint is then placed over the padding and molded to the contours of the extremity, and the stockinette and padding are folded back to create a smooth edge (Figure 1). The dried splint is secured in place by wrapping an elastic bandage in a distal to proximal direction. For an average-size adult, upper extremities should be splinted with six to 10 sheets of casting material, whereas lower extremities may require 12 to 15 sheets.

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