Boxer’s Hand Fracture
Boxer’s Hand Fracture | Denver, Colorado
A boxer’s fracture is a specific type of hand fracture I frequently treat in my hand surgery practice in metropolitan Denver, Colorado.
This injury is nearly universally caused from hitting an object, such as in boxing, a motor vehicle accident, or a fall. The force of the strike breaks the bone.
Specifically, the hand bone (ie, metacarpal) at the base of the small finger is the one that breaks in this injury pattern.
Boxer’s Hand Fracture Symptoms & Diagnosis
Figure 1 - A boxer’s fracture occurs when the 5th metacarpal, or the hand bone at the base of the small finger, breaks following an impact.
As with any broken bone, the primary symptom of a boxer’s fracture is pain after an injury. Additional clues you may have a boxer’s fracture include bruising, swelling, or a visual sense that your pinky finger knuckle has ‘disappeared.’
X-rays of your hand will confirm the diagnosis. A classic boxer’s fracture occurs when the metacarpal breaks at the neck, just below the knuckle. The head of the metacarpal then tips forward (see Figure 1). How much it tips forward, and whether it rotates at all, will determine whether you would benefit from surgical fixation of the fracture or not.
Additional tests or imaging other than x-ray are not required for a boxer’s fracture.
Boxer’s Fracture Treatment
While there is always a nuance to each fracture, there are three primary reasons to need surgery for a boxer’s fracture:
Excessive angulation
Rotation of the finger through the fracture
Inability to fully straighten finger (ie, extensor lag)
The 5th metacarpal can tolerate a significant amount of deformity. In fact, the head can be angled down and away from the shaft of the metacarpal by 50-60 degrees before we would expect any functional deficit in the hand. That means the majority of these fractures can be successfully treated without surgery.
Of course, if your finger is rotated because of the fracture or it can not fully straighten, we would want to surgically fix your fracture so the hand does not heal in this suboptimal position.
Treatment without surgery is usually begun in a cast. Following 2-4 weeks of immobilization in a cast, I will then transition you to part-time splinting with range of motion exercises to treat any developing stiffness. No lifting or heavy use of the hand can be undertaken for 6-8 weeks.
If surgery is required, then this is usually done with surgical pins. These are smooth metal pins placed through the skin to hold the bone straight while it heals. These will be removed in the office 4-6 weeks after the initial surgery.
Additional Information
This is a basic overview of boxer’s fracture injuries. If you have more specific questions about this injury, or you just want to learn more, read on below as I answer many of my patients’ most common hand fracture questions. You can also reference my ‘deep dive’ articles to the right of the FAQs for even more information on the topic.
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The Basics
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A boxer's fracture is a specific type of hand injury characterized by a broken 5th metacarpal bone in the hand. This typically occurs at the neck of the metacarpal and the metacarpal head tips forward into the palm as it displaces.
See Figure 1 above for an x-ray of a boxer’s fracture.
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A boxer's fracture is caused by a direct and forceful blow to the hand, usually occurring when the hand is clenched in a fist. The force of the impact will break the fifth metacarpal.
Common scenarios include punching a hard surface, motor vehicle accidents, or accidental falls onto the outstretched hand.
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Individuals at risk of having a boxer's fracture are those involved in activities with potential hand trauma, such as boxers, martial artists, or athletes in contact sports. I typically see this injury in younger patients, and more often in males.
Boxer’s Fracture Symptoms & Diagnosis
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As with any fracture, the primary symptom is pain. You may also notice swelling, bruising, or stiffness as a result of this injury.
In severe cases, visual deformities such as a ‘disappearance’ of your knuckle may be observed.
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X-ray is the primary means of diagnosing a boxer’s fracture. There is no secret trick to diagnosing a fracture without an x-ray. If you are concerned you may have a boxer’s fracture, you need to see a clinician to have an x-ray performed.
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Additional testing beyond a simple x-ray is not typically needed to diagnose a boxer’s fracture.
Boxer’s Fracture Treatment
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Absolutely. If your boxer’s fracture is not 1) excessively angulated, 2) causing the finger to mal-rotate, or 3) preventing you from straightening your small finger, then your fracture may be treatable without surgery.
The 5th metacarpal bone can tolerate a significant amount of deformity. The metacarpal head can be displaced down and away from the shaft of the metacarpal by 50-60 degrees before we worry about functional problems in the hand. That means the majority of these fractures can be successfully treated without surgery.
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If you have sustained an injury to your hand, there are several at-home treatments to start right away before you can get in to see a doctor. Let’s walk through how to treat your hand (or any injury) with what is commonly known as R.I.C.E. therapy.
R - Rest. If your hand hurts following an injury, try to stop using it as much as possible. Even better, obtain a standard velcro ’ulnar gutter’ brace from your local pharmacy or a friend. This will immobilize the region of your 5th metacarpal and allow your injury to rest. While this may not be enough to definitively treat your injury, this will help with the initial stages of pain and inflammation.
I - Ice. It can be very helpful to use ice on the injured hand. Be sure you have a protective layer between the ice and your skin (eg, dish towel, clothing). Do not ice the area for more than 20 minutes at a time. I typically recommend icing in a “20 minutes on, 20 minutes off” pattern.
C - Compression. Of all the stages of R.I.C.E., be the most careful with compression. Some find that some gentle compression feels good after an injury for extra stabilization. In general, we would recommend accomplishing this by using an elastic wrap bandage (Brand example: ACE wrap). However, it is crucial that you don’t stretch the elastic wrap bandage while you wrap. This will provide too much compression, and if your hand swells, you can develop a painful or even permanently damaging condition. If you are interested in using compression, be sure to gently apply the bandage and re-evaluate frequently to ensure it is not becoming too tight with your hand swelling. Never apply compression before going to sleep for the night.
E - Elevation. This is the most important one. I wish this were first in the mnemonic, but then it would spell E-R-I-C. Anyways, elevate, elevate, elevate. The higher the better. When you can, keep the hand above the level of the heart. When that’s not possible, keep your hand above your elbow. Gravity is your friend! The more you elevate your injured hand, the less swelling you will experience. The less swelling you experience, the less pain you will have. This is particularly crucial in the first few days after an injury.
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Treatment without surgery varies based on your specific fracture pattern.
In general, treatment is usually begun in a cast. Following 2-4 weeks of immobilization in a cast, I will then transition you to part-time splinting with range of motion exercises to treat any developing stiffness.
You will not be permitted to lift or use the hand in routine fashion for 6-8 weeks. This is the typical length of time required for bones to heal.
Boxer’s Fracture Surgery
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The surgery to fix a boxer’s fracture is typically what we call a closed reduction percutaneous pinning (CRPP). To perform this surgery, I place sharp wires through the skin and across the fracture to stabilize the bones.
Occasionally a small incision must be made to help realign the bones before placing the pins.
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In many cases, therapy is beneficial after a boxer's fracture. While it may not be necessary for less severe fractures, therapy can aid in restoring hand functionality, preventing stiffness, and promoting optimal healing.
Whether your fracture is treated surgically or not, Certified Hand Therapists (CHT) will guide you through exercises to improve range of motion and strength as they heal.
Fortunately, we employ many CHTs in our practice, so you will have ready access to this service following your injury.
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Remember that ‘recovery’ is a subjective term. Below is the typical outline of healing following this surgery:
Surgery - 2 weeks: Wear a post-operative splint full-time
Begin 2 weeks: Removable splint made by hand therapy, begin to work on gentle small finger range of motion exercises. No physical use of the hand.
4-6 weeks: I remove your pins in clinic. Continue with splinting, light range of motion exercises, and limited use of the hand.
6-8 weeks: Once bony healing is confirmed on x-ray and examination with me, progress strengthening of the hand and use the brace less and less.
3-4 months: Return to heavy activities and/or impact sports. Most patients feel 90% of their former selves by this point. Occasional aches and pains, or a bad day here or there are still expected.
9 months - 1 year: “Full” recovery, where you may have to stop and think to remember which hand you had injured.
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All surgeries have risks, many of which are generic to surgery itself. I go over these in detail with you before surgery as part of the informed consent process. Examples include bleeding, infection, damage to surrounding tendons/nerves/vessels, anesthesia risks, or failure of the procedure.
There are a couple of risks specific to boxer’s fracture fixation surgery that are worth highlighting.
The first is stiffness. All fractured hands (fixed with surgery or casting) will feel very stiff when beginning work with therapy. This is why therapy is so important. This usually fully resolves but can be permanent in some cases.
Another risk to understand is nonunion. This is a risk of treating any broken bone. In this situation, something goes awry in the bony healing process and your bone fails to heal. This often requires a bigger surgery to fix.
Big risk factors for nonunion include smoking, diabetes, and obesity. If you use tobacco and break a bone, you will want to quit immediately. Nicotine constricts the tiny blood vessels required to form new bone across a fracture repair site.
