SplintER Series: Punched a Wall

X ray boxer's fracture

A 27-year-old male presents to the ED with left hand pain after punching a wall. He has pain and swelling on the ulnar side of the dorsal hand. The above hand radiographs were obtained (image courtesy of Mark Hopkins).

This patient has a fracture of the 5th metacarpal neck, otherwise known as a Boxer’s fracture. It is so named because a majority of these fractures come from punching an object [1].

  • Pearl: Unlike most hand and wrist fractures, metacarpal fractures are more likely to occur from axial loading than from a fall onto an outstretched hand (FOOSH) [1].

1. Skin:

  • Closely observe for any breaks on the dorsal surface, especially near the MCP joint, as this can indicate an open fracture which would require operative irrigation, debridement, and antibiotics.

2. Angulation:

  • Observe for any obvious malalignment. Dorsal angulation may cause depression of the MCP joint and disappearance of the normally appearing knuckle [1].

3. Neurovascular:

  • As always, any neurovascular deficits should prompt surgical consultation.
  • Pearl: Given the tight fascial layers of the hand, keep compartment syndrome in mind.

4. Rotational Alignment:

  • Observe by having the patient make a fist and checking for proper finger alignment. Extending lines from the fingers should show eventual convergence at the scaphoid. Any degree of malrotation warrants urgent surgical consultation [3].

Image of hand malrotation

Opinions vary, but most agree that any angulation beyond 30 degrees at the metacarpal neck requires reduction [1].

  • PEARL: Anesthesia can be achieved by an ulnar nerve or hematoma block, with reduction accomplished by applying dorsal pressure with the MCP, PIP, and DIP in flexion.

Patients should be placed in an ulnar gutter splint. They can follow up with a hand specialist as determined by institutional policy as an outpatient in 1 week.

  • Pearl: Studies have shown that patients with less than 60 degrees of angulation can be managed non-operatively and expect a full functional recovery. Cosmetic defects may occur, but are often preferable to surgical intervention if function is kept [4].
  • Pearl: If the fracture is comminuted, significantly angulated, malrotated, or intraarticular, educate the patient the possibility of surgical fixation [4].


Looking to bone up in general? Check out the SplintER archives. Want more information on hand radiographs? Check out SplintER Series: Case of a First Metacarpal Fracture or Trick of the Trade: Reducing the metacarpal neck fracture.

  1. Malik S, Herron T, Rosenberg N. Fifth Metacarpal Fractures (Boxer’s Fracture). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. PMID: 29261999
  2. Nakashian MN, Pointer L, Owens BD, Wolf JM. Incidence of metacarpal fractures in the US population. Hand (NY). 2012;7(4):426-430. PMID: 24294164
  3. Yang S, Kim JP. Hand Fractures. J Korean Fract Soc. 2018 Apr;31(2):61-70. DOI: 10.12671/jkfs.2018.31.2.61
  4. van Aaken, J, et al. Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial. Archives of Orthopaedic and Trauma Surgery: Including Arthroscopy and Sports Medicine. January 2016 136(1):135-142. PMID: 26559192