Does a boxer's fracture with shortening require referral?

From the Guidelines

A boxer fracture with shortening greater than 3 mm should be referred to a specialist for potential surgical fixation. This recommendation is based on the most recent and highest quality evidence available, which suggests that fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement should be considered for surgical fixation 1. The primary concern with boxer fractures that have significant shortening is the potential for long-term functional problems, including decreased grip strength, knuckle prominence deformity, and rotational issues that affect finger alignment.

Some key points to consider in the management of a boxer fracture with shortening include:

• The degree of shortening: fractures with shortening greater than 3-5mm are more likely to require surgical intervention
• The presence of intra-articular displacement or dorsal tilt: these factors can also influence the decision to refer for surgical fixation
• The timing of referral: prompt referral, ideally within a few days of injury, is crucial to prevent delayed treatment and potential permanent deformity
• Pain management: acetaminophen or NSAIDs like ibuprofen (400-600mg every 6-8 hours) can be used to manage pain, along with ice application and elevation of the hand to reduce swelling.

It is essential to prioritize referral to a specialist for boxer fractures with significant shortening to ensure optimal outcomes and minimize the risk of long-term functional problems. The evidence from 1 supports this approach, emphasizing the importance of surgical fixation for fractures with significant displacement or shortening.

From the Research

Boxer Fracture Management

• The management of boxer's fractures varies greatly, with some studies suggesting that conservative management is suitable for closed, non-displaced fractures with minimal angulation 2, 3, 4.
• The acceptable angulation for conservative management is generally considered to be 70 degrees or less, although one study found good functional outcomes for patients with 50° or less palmar angulation who were discharged with no follow-up 2, 4.
• Non-operative management is typically recommended for fractures that are closed, non-displaced, and without significant angulation or rotation, while open fractures, fractures with significant angulation or mal-rotation, and fractures with neuro-vascular injury may require operative management 3, 4.

Shortening of the Fracture

• The studies do not provide a clear consensus on whether shortening of the fracture is a contraindication for conservative management 2, 3, 4.
• However, one study suggests that shortening of the finger is a factor to be considered in the management of boxer's fractures, and that buddy strapping with a Futura splint can provide good functional results even in cases with some shortening 4.

Relevant Studies

• A literature review published in 2020 found that conservative management is the preferred option for closed, non-angulated, non-malrotated fractures, while surgical intervention is recommended for open fractures, significant angulation, rotational deformity, and intra-articular extension 3.
• A study published in 2024 found that non-operative management is suitable for fractures that are closed, non-displaced, and without angulation or rotation, and that K-wire fixation is a minimally invasive method of fixation that can provide good functional results in cases requiring operative intervention 4.