Treatment of Boxer's Fracture
For uncomplicated boxer's fractures (fifth metacarpal neck fractures) with palmar angulation ≤70 degrees and no rotation, immediate mobilization with a pressure bandage or soft wrap for 1 week is the recommended treatment—cast immobilization is not necessary and provides no functional benefit. 1, 2
Initial Assessment and Treatment Decision
The key determinants for treatment are:
- Degree of palmar angulation: Up to 70 degrees is acceptable without reduction 1
- Presence of rotation: Any rotational deformity requires operative consideration 1
- Angulation ≤50 degrees: Can be safely discharged without follow-up 3
Conservative Management (First-Line Treatment)
Immediate mobilization is superior to cast immobilization for functional outcomes:
- Apply a pressure bandage or soft wrap for 1 week only 1, 2
- Begin immediate mobilization within pain limits 1
- No formal reduction is required for angulation up to 70 degrees 1
Evidence Supporting Conservative Approach
- Conservative management provides equivalent functional outcomes (Quick-DASH scores, grip strength, Total Active Motion) compared to operative treatment 4
- Patients return to work earlier with conservative treatment compared to surgery 4
- Cast immobilization shows no superiority over soft wrap in terms of range of motion, patient satisfaction, pain perception, or return to activities 1, 2
- Most patients with ≤50 degrees angulation return to work immediately with good functional outcomes 3
When to Consider Operative Management
Operative intervention should be reserved for:
- Rotational deformity (any degree) 1
- Angulation >70 degrees 1
- Open fractures
- Multiple metacarpal fractures
Important Caveat
While operative management achieves better radiological correction of palmar angulation, this does not translate to improved functional outcomes or patient satisfaction 4. The cosmetic appearance of residual angulation rarely causes functional impairment in the fifth metacarpal.
Rehabilitation Protocol
- Week 1: Pressure bandage with immediate finger motion within pain tolerance 1
- After 1 week: Remove bandage and continue progressive mobilization 1
- Formal physiotherapy is rarely needed for uncomplicated fractures 1
- Early finger motion prevents edema and stiffness 5
Common Pitfalls to Avoid
- Over-treatment with prolonged immobilization: 3-week cast immobilization provides no benefit over 1-week soft wrap 1
- Unnecessary reduction: Attempting reduction for angulation <70 degrees has no value for functional outcomes 1
- Routine orthopedic referral: Uncomplicated fractures with ≤50 degrees angulation can be managed without specialist follow-up 3
- Concern about cosmetic deformity: Residual angulation rarely causes functional problems and patients report high satisfaction 1, 4