What is the recommended treatment for a boxer fracture?

Management of Boxer's Fracture

Conservative treatment with early mobilization is the recommended first-line approach for most boxer's fractures (fifth metacarpal neck fractures) with volar angulation up to 70 degrees, as it provides equivalent functional outcomes to surgical intervention with earlier return to work and no risk of surgical complications.

Assessment and Classification

• Boxer's fracture is a fracture of the fifth metacarpal neck typically resulting from direct trauma to a clenched fist
• Key assessment parameters:
  • Degree of volar angulation
  • Presence of rotation
  • Shortening of the metacarpal
  • Open vs. closed fracture
  • Intra-articular extension

Treatment Algorithm

Conservative Management (First-Line)

• Indications:

  • Closed fractures
  • Volar angulation up to 70 degrees
  • No rotational deformity
  • No significant shortening (less than 5mm)
  • No intra-articular extension

• Protocol:

  1. Pressure bandage for 1 week followed by immediate mobilization 1
  2. Alternative: Ulnar gutter splint with the MCP joint flexed at 60-90 degrees for 1-3 weeks 2
  3. Early functional treatment to preserve range of motion

• Evidence Support:

  • Research shows equivalent functional outcomes between conservative and surgical management despite worse radiological alignment 3
  • Immediate mobilization provides good results with volar angulation up to 70 degrees 1
  • Conservative treatment results in fewer days off work compared to surgical intervention 3

Surgical Management

• Indications:

  • Open fractures
  • Volar angulation >70 degrees
  • Rotational deformity
  • Significant shortening (>5mm)
  • Intra-articular extension
  • Multiple metacarpal fractures

• Surgical Options:

  • Percutaneous K-wire fixation
  • Intramedullary fixation
  • Open reduction and internal fixation with plates and screws

Important Clinical Considerations

1. Angulation Tolerance:

   • The fifth metacarpal can tolerate significant volar angulation (up to 70 degrees) without functional impairment 1
   • Attempts at closed reduction of boxer's fractures are often unsuccessful in maintaining reduction 2

2. Functional Outcomes:

   • Despite radiographic differences, functional outcomes (grip strength, range of motion, pain) are equivalent between conservative and surgical management 3

3. Rehabilitation:

   • Early mobilization is key to good functional outcomes
   • Physical therapy may be necessary for patients with persistent stiffness

4. Return to Activities:

   • Most patients can return to light activities within 3-4 weeks
   • Return to contact sports typically at 8-12 weeks

Pitfalls and Caveats

• Rotational deformity is poorly tolerated and must be addressed surgically to prevent functional impairment
• Don't be overly concerned with radiographic appearance if function is preserved
• Avoid prolonged immobilization which can lead to stiffness and decreased range of motion
• For conservative management, ensure the MCP joint is flexed during immobilization to prevent collateral ligament contracture

By following this approach, most boxer's fractures can be effectively managed with good functional outcomes and minimal complications.