Abstract
Objective: Through this case study I am going to present information on a fracture to the neck of
the fifth metacarpal, otherwise known as a Boxer’s Fracture. Through this information regarding;
mechanism, assessment, diagnosis, treatment, rehabilitation, prevention, and criteria to return to
play after the injury will become clearer. Background: A Boxer’s Fracture is a fracture to the
neck of the fifth metacarpal bone of the hand. This injury is caused by punching a solid object
with a closed fist. This fracture can also occur when the hand is not closed in a fist but
outstretched when is hits a hard object. In this specific case the athlete had his hand in a closed
fist and punched someone else causing him to break his fifth metacarpal bone at the neck.
Differential diagnosis: Other injuries that could present some of the same signs and symptoms
include: a contusion to the fifth metacarpal, or a hematoma in the area of the fifth metacarpal.
Treatment: Always beings after diagnosis with simple plans of attack like ice and rest. This
athlete would also be splinted right away in order for the fracture to heal properly. Nonsurgical
means of reduction are the first option, if this is not possible surgical intervention may be
necessary. After the athlete is put in a cast for 3 to 4 weeks they would be able to begin a
rehabilitation program including strengthening and range of motion. Prevention: The easiest
way to prevent this type of injury is by staying out of fist fights and to refrain from punching
solid objects like file cabinets, and walls. In-taking the proper amount of calcium in younger
years as well as later in life plays a large part in helping bone strength as well. Conclusion:
Boxer’s Fractures can be easily avoided and take at least a month in order to begin any activity
after it occurs. Seeing as the hand is an important part of the body this is not an injury to mess
with and should be taken care of immediately. Staying away from fights and punching hard
objects while frustrated is the first line of defense. Once the injury has occurred, gaining strength
and range of motion in that hand is the first course of rehabilitation.
Personal Data
This injury occurred to a 21 year old male football player from Rowan University.
Chief Complaint
The athlete was in a casual setting, off campus, with his friends over the weekend when
the injury occurred. He got into an altercation with another young male and with his left hand,
made into a fist, punched him in the face. At the time of impact he felt a crack on the medial side
of his left hand. The following Monday he came into the athletic training room with his left hand
in the front pocket of his sweatshirt. The athlete informed us of the incident over the weekend
and stated that had not injured this hand before that incident. He was having pain on the medial
side of his left hand, and there was obvious swelling and deformity. As I previously stated he had
it resting in the pocket of his sweatshirt which means he was guarding it as he walked around
campus.
Result of Physical Examination
The physical examination showed a large amount swelling and deformity over the medial
side of his left hand, proximal to his little finger. The observation showed the signs there because
that is the site of a common metacarpal fracture. This fracture is otherwise known as a Boxer’s
Fracture. A boxer’s fracture is a fracture to the neck of the fifth metacarpal. That type of fracture
is caused by hitting a solid object with a closed fist in junction with an axial load of the hand.
As the evaluation continued it was found that, due to pain the athlete was guarding his
hand in his sweatshirts’ front pocket. He was not moving his wrist or fingers due to pain, and
probably because of the swelling, as well. On a pain scale of 0 to 10, with 10 being the worst
pain ever, he was at a 7. Some other signs and symptoms that are common with a boxer’s
fracture include; inability to grip, possible crepitus and possible false motion (Gallaspy).
Through palpations he was positive for pain over the fifth metatarsal, and the surrounding area.
At this point crepitus of the area was also found.
No range of motion testing or manual muscle tests were performed during the evaluation
because he was suspected of having a fracture to the firth metacarpal. Due to this, all range of
motion and strength tests are contraindicated and should not be done. All circulation and
neurological tests were within normal limits for the wrist and hand as well. Functional tests like
grip were performed and he did not have the strength in his left hand that he had in his right
hand.
In order to make a proper diagnosis some special tests were performed. The athlete had a
positive Tap Test. Positive meaning he had pain radiating down the fifth phalanx and fifth
metacarpal when performed. A Compression Test was also performed and was positive for pain
as well. Another test that could have been performed at this time is an Axial Load Test
(Gallaspy). After the evaluation was performed it was recommended that he should get X-rays of
the injured hand.
Result of Medical History
When the results from the X-ray came back it was clearly shown that he had a fracture to
the neck of the fifth metacarpal. The fracture to the Rowan athlete was not able to be reduced
non-operatively and he had surgery to get it pinned back into place. Requirements for operative
fixation include severe angulation not treatable by closed means, unstable rotational deformity,
or significant comminution or bone loss (Dye). The Rowan athlete had severe angulation making
surgery necessary. Following surgery he was placed in a cast for 3 to 4 weeks.
Diagnosis
The impression that I received from the evaluation was that the athlete suffered from a
fracture to the neck of the fifth metacarpal of his left hand. The injury is also known as a boxer’s
fracture because of the mechanism used to obtain it, punching an object with a closed fist
(Hernandez). I was able to come to this conclusion because of the information I received during
the assessment. The pain on the medial side of the hand plus the swelling, deformity, and
positive special tests gave me a good indication of the pathology I was presented with. In the end
the mechanism itself, punching someone, and the results of the X-rays were great indications that
the athlete had a Boxer’s Fracture.
Treatment and Clinical Course
After it was discovered that the athlete had a boxer’s fracture he was put in a splint until
he was able to get it reduced. At this time he was also advised to ice, rest and elevate the hand as
well as take anti-inflammatory medication and pain killers as needed. He was also told not to
play sports or try to pick anything up with that hand, because he could injure it further if he did.
The next step was for him to see an orthopedic surgeon, who decided that non-operative means
would not be able to reduce the fracture, and as I previously stated he did have surgery in order
to reduce and pin the bone back into place.
In this case he was put into a cast and could not move his wrist or fifth phalanx for 3 to 4
weeks. It is said that the most affective surgical treatment allows for immediate motion of the
hand in order to reduce the likely hood of stiffness (Dye). Although he did not have that type of
freedom the rehabilitation program he started during week 4 focused on strength and range of
motion, and joint mobilization. Gaining proper grip strength was a main priority and could be
obtained by using “gripping putty, a rubber ball, or hand grip coils (Prentice).” Active range of
motion for all motions of the wrist and fingers was also performed in order to gain back what
was lost. Other exercises called dexterity exercises are a normal part of rehabilitation for a
boxer’s fracture. These types of exercises are used in everyday living as well as athletics so they
are very important. The exercises would include pinching, tearing tape, picking up coins, or
gripping balls (Prentice).
The athlete was in the mindset that he was going to be able to practice with the team for
spring training at Rowan, so that was the goal that was set for him. He followed his rehabilitation
program and gained full range of motion to his left hand, and full strength with enough time to
complete spring training with the rest of the football team. He has since gone on to normal and
full activity and continues to progress. At this point making sure he has no pain, or deficits in
strength, to that hand are the main priorities in order for him to continue playing football, at the
college level.
Criteria for Return
In order for this athlete to return to football he had to gain full grip strength back to his
left hand. Grip strength is important in everyday life, and in order to play a sport, like football,
you absolutely need it. In order to determine that he was ready to return he had to go through a
series of functional tests to prove he had no pain, lack of range of motion, or strength deficits in
his left hand due to his injury. Catching a tennis ball or holding something in his hand while the
examiner tries to pull it out are examples of functional tests that could be performed. Also,
performing proper active, passive, and resistive range of motion testing bilaterally to determine if
he is able to return to play was important as well.
Discussion
Although the cause of my case study did not come from an on field or sports related
injury it can happen to an athlete during a game or match. The information in the case study is
especially important to Athletic Trainers who will be working with athletes in high contact sports
like Football, Hockey, and even wrestling. The high contact sports give athletes more
opportunities to be subject to the mechanism that causes a Boxer’s Fracture.
This injury is unique because it accounts for only 10 percent of all hand injuries (Dye). I
believe it is also important to learn about because it can happen to males, and females of any age.
The specific case I reported was unique because it happened to an athlete while he wasn’t even
participating in a sport; he was in a casual setting and gave himself the injury with the most
common mechanism of punching a solid object.
Conclusion
Over all this injury can be prevented in most cases. Most people receive this injury by
hitting a solid object with a closed fist improperly. Boxer’s are less likely to receive this injury,
although it is called a boxer’s fracture, because boxers know the proper way to hit a solid object
without putting themselves in danger (Hernandez). In the end this athlete showed that he had the
drive and patience to return to play safely and in a timely fashion. He completed the
rehabilitation program and was able to complete spring training at full activity with the rest of
the team. Because he completed his rehabilitation and took it seriously he is only helping himself
to be in better shape for the start of the 2008 football season at Rowan University.
Works Cited
Dye, T Michael. "Metacarpal Fractures." eMedicine 19313 Feb 2008 23 Apr 2008
<http://www.emedicine.com/orthoped/topic193.htm>.
Gallaspy, James B.. Signs and Symptoms of Athletic Injuries. St. Louis: Mosby-Year Book, Inc,
1996.
Hernandez, Manuel. "Boxer's Fracture." eMedicineHealth. 2008. WebMD. 1 May 2008
<http://www.emedicinehealth.com/boxers_fracture/article_em.htm>.
Prentice, William E.. Rehabilitation Techniques in Sports Medicine. St. Louis: Times
Mirror/Mosby College Publishing, 1990.