What is the appropriate initial evaluation and management for a 16-year-old patient with a history of punching a cement wall, presenting with achy and sharp pain (8/10) on the edge of the right hand, just below a couple of knuckles, which decreases with movement, without numbness, tingling, or radiation, and no previous similar injuries or hand conditions mentioned?

Essential History and Physical Examination Questions for Suspected Boxer's Fracture

You need to obtain plain radiographs immediately—at minimum a 3-view hand series (PA, lateral, and oblique)—to rule out metacarpal fracture (likely 4th or 5th metacarpal neck fracture, aka "boxer's fracture") and assess for rotational deformity. 1

Critical History Questions to Ask Now

Mechanism and Timing Details

• Exact location of impact: Which knuckles made contact with the wall? (4th and 5th metacarpal neck fractures are most common with punching injuries) 1
• Time since injury: How many hours/minutes ago did this occur? (Critical for compartment syndrome risk assessment) 2, 3
• Immediate vs. delayed swelling: Did swelling occur immediately or gradually? (Immediate suggests more severe soft tissue injury or possible compartment syndrome) 2

Functional Assessment

• Grip strength: Can he make a fist? How strong compared to the other hand? 4
• Finger cascade alignment: When he makes a gentle fist, do all fingers point toward the scaphoid, or does any finger cross over another? (Rotational deformity indicates unstable fracture requiring surgical consideration) 5, 1
• Active range of motion: Can he fully extend and flex each finger individually, especially the ring and small fingers? 5

Red Flags for Compartment Syndrome

• Progressive pain: Is the pain getting worse despite rest, or does it seem out of proportion to the injury? (Early warning sign) 2, 3, 6
• Pain with passive finger extension: Does it hurt when you gently straighten his fingers for him? (Classic early sign of compartment syndrome) 2, 6
• Tightness or firmness: Does the hand feel tight, swollen, or "about to burst"? 2, 3

Critical Physical Examination Findings

Inspection

• Knuckle depression or asymmetry: Loss of normal knuckle prominence suggests metacarpal neck fracture with volar angulation 1
• Rotational deformity: Finger scissoring or malrotation when making a fist 5, 1
• Open wounds or skin breaks: Any laceration requires wound management first and consideration of open fracture 5

Palpation

• Point tenderness location: Palpate each metacarpal head and shaft individually 1
• Compartment tension: Assess firmness of intrinsic hand muscles (thenar, hypothenar, interosseous compartments) 2, 3
• Capillary refill: Should be <2 seconds in all fingertips 2

Neurovascular Assessment

• Two-point discrimination: Test ulnar nerve distribution (small finger and ulnar half of ring finger) 4
• Motor function: Test finger abduction/adduction (interossei), thumb opposition (median nerve), and finger extension at MCP joints 4
• Radial and ulnar pulses: Document presence and quality 4

Immediate Imaging Protocol

Order a minimum 3-view hand series (PA, lateral, and oblique views) immediately. 1 The lateral view is essential to assess volar angulation of the metacarpal neck, and the oblique view increases diagnostic yield for subtle fractures. 1

If Radiographs Show Fracture

• Acceptable angulation: 4th metacarpal neck can tolerate up to 40° volar angulation; 5th metacarpal neck up to 50° 1
• Rotational deformity >3mm displacement or >1/3 articular surface involvement requires orthopedic referral for possible surgical fixation 5
• Buddy taping and early range of motion: For stable, minimally displaced fractures 5

If Initial Radiographs Are Normal But High Clinical Suspicion

• Immobilize in short arm splint and repeat radiographs in 10-14 days, OR proceed directly to MRI without IV contrast 1 to evaluate for occult fracture, ligamentous injury, or bone contusion

Compartment Syndrome Vigilance

This is a limb-threatening emergency that can occur even after "relatively minor" mechanisms. 2 The classic "5 Ps" (pain, pallor, pulselessness, paresthesias, paralysis) represent irreversible muscle necrosis—you must diagnose earlier. 3, 6

Early Warning Signs (Act Before 5 Ps Develop)

• Pain out of proportion to injury 2, 3, 6
• Pain with passive finger stretch 2, 6
• Progressive tightness or swelling 2, 3
• Decreased pulse oximetry or cool extremity 2

If any concern for compartment syndrome exists, immediate orthopedic consultation for possible fasciotomy is required. 3, 6 Delayed decompression leads to permanent functional impairment, renal failure, and potentially death. 2, 6

Follow-Up Protocol

• Reassess within 24 hours (phone or office visit) to evaluate for worsening symptoms 5
• Immediate return if pain worsens or function deteriorates 5
• Patient education: Instruct to seek immediate care for numbness, deep pain, coolness, or inability to move fingers 2