Treatment of Boxer's Fracture with a Split
For a boxer's fracture (fifth metacarpal neck fracture) with a split or open wound, immediately cover the wound with a clean dressing, then immobilize the hand with an ulnar gutter splint in the position found, and refer urgently to orthopedics for evaluation of the open fracture. 1
Immediate Management of the Open Wound
- If the fracture is associated with an open wound and severe bleeding, control hemorrhage first using direct pressure before addressing the fracture itself 1
- Cover any open wound with a clean dressing immediately to reduce contamination and infection risk 1
- Activate emergency medical services if the hand appears blue, purple, or pale, as this indicates compromised perfusion requiring immediate intervention 1
Immobilization Approach
- Splint the fractured hand in the position found rather than attempting reduction in the field 1
- Use a padded ulnar gutter splint to immobilize the fourth and fifth metacarpals and prevent further injury 1, 2
- Do not attempt to straighten or manipulate the fracture unless absolutely necessary for safe transport 1
- Splinting reduces pain, prevents additional soft tissue injury, and facilitates transport to definitive care 1
Key Clinical Caveat: Open vs Closed Fractures
The term "split" suggests an open fracture, which fundamentally changes management compared to the typical closed boxer's fracture. While closed boxer's fractures with angulation up to 50-70 degrees can often be managed conservatively with minimal immobilization or even just a pressure bandage 3, 4, 5, open fractures require urgent orthopedic consultation, antibiotics, and possible surgical debridement to prevent osteomyelitis and other complications.
Definitive Care Considerations
Once at a medical facility with an open boxer's fracture:
- Antibiotic prophylaxis should be initiated immediately for open fractures 1
- Surgical irrigation and debridement may be necessary depending on wound contamination 1
- Tetanus prophylaxis should be updated as appropriate
- Radiographic evaluation is essential to assess fracture pattern and degree of angulation 6
Important Distinction from Closed Boxer's Fractures
For closed boxer's fractures without skin compromise, the evidence strongly supports conservative management. Studies demonstrate that angulation up to 70 degrees can be managed with immediate mobilization after brief soft wrap immobilization, with excellent functional outcomes 3, 5. However, the presence of an open wound ("split") elevates this to a surgical emergency requiring different protocols than the typical closed boxer's fracture.