Boxer's fracture: Difference between revisions

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[[File:Boxer-fracture-12.jpg|thumb]]
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   Caption        = |
   DiseasesDB    = |
   DiseasesDB    = |
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   ICD10          = {{ICD10|S|42|2|s|40}}-{{ICD10|S|42|4|s|40}} |
   ICD9          = |
   ICD9          = {{ICD9|812}} |
   ICDO          = |
   ICDO          = |
   OMIM          = |
   OMIM          = |
   MedlinePlus    = |
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  eMedicineSubj  = emerg |
  eMedicineTopic = 199 |
  eMedicine_mult = {{eMedicine2|orthoped|271}} {{eMedicine2|orthoped|199}} |
   MeshID        = |
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{{SI}}
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{{CMG}}
 
{{CMG}}; {{AE}}[[User:DrMars|Mohammadmain Rezazadehsaatlou[2]]].
==Overview==
==Overview==
The [[Boxer's fracture]] is a fracture of the base of the 5th metacarpal neck and known as the most common metacarpal fracture . The early diagnosis and treatment are imperative to prevent loss of function of this highly mobile human joint system.
== Historical Perspective ==
There are no reliable information regarding the historical perspective of the [[Boxer's fracture]].
==Causes==
The main etiology of the [[Boxer's fracture]] is an axial load to the 5th metacarpal. Usually its a result of a direct force using a clenched fist against a solid surface area such as human face, wall, or tree.
As a person age, two factors cause higher risk of fractures:
* Weaker bones
* Greater risk of falling
Stress fractures as a common causes of fractures can be found due to the repeated stresses and strains. Importantly children having more physically active lifestyles than adults, are also prone to fractures. People with any underlying diseases such as osteoporosis, infection, or a tumor affecting their bones having a higher risk of fractures. As mentioned in previous chapters, this type of fracture is known as a pathological fracture. Stress fractures, which result from repeated stresses and strains, commonly found among professional sports people, are also common causes of fractures.
===Life-threatening Causes===
*There are no life-threatening causes of  [[Boxer's Boxer's fracture]] ''',''' however complications resulting from [[Boxer's fracture]]  is common.
===Common Causes===
Common causes of  [[Boxer's fracture]]  may include:
*Direct [[Trauma]] (Fall on an outstretched hand)
===Less Common Causes===
Less common causes of '''[[Boxer's fracture]]'''  include conditions that predisposes to fracture:
*[[Osteoporosis]]
*[[Osteopenia]]
*[[Malignancy|Malignancies]]
===Causes by Organ System===
{| style="width:80%; height:100px" border="1"
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" |'''Cardiovascular'''
| style="width:75%" bgcolor="Beige" ; border="1" | No underlying causes
|-
| bgcolor="LightSteelBlue" | '''Chemical/Poisoning'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Dental'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Dermatologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Endocrine'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Environmental'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Genetic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Hematologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Iatrogenic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Infectious Disease'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Musculoskeletal/Orthopedic'''
| bgcolor="Beige" | [[Osteoporosis]] and [[osteopenia]].
|-
|- bgcolor="LightSteelBlue"
| '''Neurologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Nutritional/Metabolic'''
| bgcolor="Beige" | [[Osteoporosis]] and [[osteopenia]].
|-
|- bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Oncologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Ophthalmologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Overdose/Toxicity'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Psychiatric'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Pulmonary'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Renal/Electrolyte'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Rheumatology/Immunology/Allergy'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Sexual'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Trauma'''
| bgcolor="Beige" | Falling of car accident
|-
|- bgcolor="LightSteelBlue"
| '''Urologic'''
| bgcolor="Beige" | No underlying causes
|-
|- bgcolor="LightSteelBlue"
| '''Miscellaneous'''
| bgcolor="Beige" | No underlying causes
|-
|}
===Causes in Alphabetical Order===
List the causes of the disease in alphabetical order:
<div style="-moz-column-count:3; column-count:3;">
* [[Trauma]]
* [[Osteopenia]]
* [[Osteoporosis]]
</div>
== Pathophysiology ==
=== Mechanism ===
The [[Boxer's fracture]] is caused by a falling or any types of trauma affecting the patients hand and specifically the 5th metacarpal joint. The form and severity of this fracture depends on the position of the hand at the moment of hitting the ground. The width of this mentioned angle affects the localization of the fracture.
=== Pathophysiology ===
Its known that the [[Boxer's fracture]] in normal healthy adults can be caused due to the high energy load such as fighting using fist to fight.
But it should be noted that the most important Risk factors for insufficiency fractures is chronic metabolic disease such as steoporosis, osteopenia, eating-disordered behavior, higher age, prolonged corticosteroid usage, female gender, lower BMI, history of a recent falling, and prior fracture.
* The pattern of bone fracture and severity of injury depends on variety of factors such as:
** Patients age
** Patients Weight
** Patients past medical history specifically any bone diseases affecting the quality of bone (such as osteoporosis, malignancies)
** Energy of trauma
** Bone quality
** Position of the specific organ during the trauma
* The below-mentioned processes cause decreased bone mass density:
** [[Autophagy]] is the mechanism through which [[Osteocyte|osteocytes]] evade [[oxidative stress]].
** The capability of [[autophagy]] in cells decreases as they age, a major factor of [[Ageing|aging]].
** As [[Osteocyte|osteocytes]] grow, viability of cells decrease thereby decreasing the bone mass density.
==Differentiating  [[Boxer's fracture]] from other Diseases==
In the orthopedic medicine its important to know that the forearm fracture should be evaluated using radiography for both confirming diagnosis and also for evaluating the surrounding tissues. Other injuries such as possible hand fracture-dislocation; radial head or coronoid fractures or lateral collateral ligament injury. If the mechanism of injury suggests particularly low energy then the Osteoporosis should be considered. The pathological Fractures occurring in a bone with a tumor or Paget's disease) are rare but possible.
Also it should be noted that the both bone fractures can be complicated by acute compartment syndrome of the forearm. Signs suggesting compartment syndrome are pain on extension of digits, and marked edema.
As another important fact in orthopedic fracture is if both-bone fractures were found in pediatric which is common after accidental trauma, but it may also be the due to the of child abuse; and in these cases a careful attention and evaluation should be considered if a child abuse is suspected
Differential Diagnoses for the Boxer's fracture:
* Boxer knuckle
*Bennett's fracture
* Rolando's fracture
* Pseudo-Bennett fracture
==Epidemiology and Demographics ==
The total fractures of the thumb are common in children (22% of hand fractures affecting the in the thumb) and the elderly (20% of hand fractures affecting the in the thumb) population.
==Risk Factors ==
There are different risk factors that predispose patient for the [[Boxer's fracture]] that include:
* High-risk contact sports
* Higher age (elderly adults are higher prone to such fractures)
* Reduced bone density (osteoporosis)
* Direct blow
* Road / traffic accidents
* Falling on an outstretched hand with the forearm pronated
* Direct trauma to the arm/forearm
* Taking part in any rough or high-impact sport
* Street fights, gunshot wounds, and domestic violence, may also cause the Boxer's fracture
* Road traffic accidents.
== Classification ==
{| class="wikitable"
|+'''Classification of the first metacarpal fractures'''
|'''Name'''
|'''Type'''
|'''Features'''
|-
|Oblique
|Extra-articular
|• oblique fracture line not involving the articular surface<br />
|-
|Transverse
|Extra-articular <br />
|• a pure transverse fracture line not involved the articular surface<br />
|-
|Bennett
|Intra-articular
|• intra-articular fracture with a palmar radial fragment
|-
|Rolando
|Intra-articular<br />
|• Y or T shaped complete intra-articular fracture
|-
|Comminuted
|Intra-articular
|• severely comminuted complete intra-articular fracture  
|}
==Screening==
Osteoporosis is an important risk factor for human affecting human bone especially in men with the age of older than 50 years old and [[postmenopausal]] and women.
Based on the [[US Preventive Services Task Force|US Preventive Services Task Force (USPSTF)]] there are three groups of patients need to be screened for the [[osteoporosis]]:
* ·       Men with no history of [[osteoporosis]]
* ·       Women with the age of 65≤ year old, with no previous history of pathological [[fracture]] due to the [[osteoporosis]]
* ·       Women with the age of <65 years, with 10-year [[fracture]] risk of not less than a 65-year-old white woman (who has not any other risk factor)
Accordingly women older than age of 50 are the main target for the [[osteoporosis]] screening. There is no specific recommendation to screen men for the [[osteoporosis]].
The [[USPSTF]] recommendations from 2002 included:
Meanwhile, there are two major modalities for the [[osteoporosis]] screening:
# ·       [[Dual energy X-ray absorptiometry|Dual energy x-ray absorptiometry (DXA)]] of the [[hip]] and [[lumbar spine]] [[bones]]
# ·       Quantitative [[ultrasonography]] of the [[calcaneus]]
<nowiki>*</nowiki>It should be noted of the two above mentioned modalities for screening the ultrasonograhy is preferred to the DXA due to its lower cost, lower [[ionizing radiation]], more availability.
After the primary evaluation of the [[osteoporosis]], the further evaluation are required in some cases such as:
·       Women with normal [[bone density]] or mild [[osteopenia]]: T-score of greater than −1.50 – should have screening for 15 years.
·       Women with moderate [[osteopenia]]: T-score of −1.50 to −1.99 – should have screening for 5 years.
·       Women with advanced [[osteopenia]]: T-score of −2.00 to −2.49 - should have screening for 1 year.
==Natural History, Complications and Prognosis ==
=== Natural History ===
In cases with untreated [[Boxer's fracture]] the malunion and deformity of arm can be occurred.


A '''boxer's fracture''', also known as the '''brawler's fracture''' is the common name for a [[fracture (bone)|fracture]] at the neck of the [[fifth metacarpal]] bone.
=== Complications ===
The overall complication rate in the treatment of [[Boxer's fracture]] were found in around 40% of cases:
# Neurovascular compromise: such as Ulna nerve damage
# Compartment syndrome
# Chronic disability of the DRUJ
# Physeal Injury
# Malunion of the radius
# Nonunion
# Infection
# Refracture following plate removal
# Posterior interosseois nerve (PIN) injury.
# Instability of the DRUJ
# Loss of Motion (Stiffness)
# Posttraumatic Arthritis
# Heterotopic Ossification


==Causes==
=== Prognosis ===
It is usually caused by the impact of a clenched fist with an immovable object, such as a [[wall]] or [[skull]]. The pinky knuckle tends to lead the rest of the knuckles in a hard punch, and the knuckle compresses and snaps the head of the metacarpal bone.
The prognosis of the [[Boxer's fracture]] is most closely related to the amount of energy and the main direction of the trauma. High-energy injuries leading to a poor outcome due to the comminution, articular surface damage, and extensive soft-tissue injury. But the good prognosis can be found in low-energy injuries with simple fracture patterns and limited soft-tissue involvement which the anatomic restoration of the joint surface and reestablishment are stable, the outcome is routinely good, especially in low-energy injuries with simple fracture patterns and limited soft-tissue involvement.


==Diagnosis==
==Diagnosis==
On imaging, transverse fracture of the metacarpal neck, with volar angulation of the distal fragment is seen.
The diagnosis of a [[Boxer's fracture]] should be confirmed using a radiographic examination.


<gallery>
==History and Symptoms ==
Image:
The related signs and symptoms include:
* Deformity
* Skin lacerations
* Weak pulse
* Open fractures
* Bruising
* Swelling
* Stiffness
* Inability to move
* Pain in touch
* Loss of function of the forearm
* Difficulties in detection of pulses
* Radial nerve damage
In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the forearm. In MULTI-trauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the [[compartment syndrome]], and the compartment pressures should be measured and monitored. Normally the pain and soft-tissue swelling are found at the injury site (at the wrist joint). This injury should be confirmed using a radiographic evaluations. Also, patients may loss the pinch mechanism between their thumb and their index finger which can be due to the paralysis of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP).


Boxers-fracture-001.jpg
==Physical Examination==
The related signs and symptoms include:
* Edema of the shoulder
** Most of the time the edema will be a non-pitting edema
** Depends on the edema extent, it may even lead to compartment syndrome in the anterior and internal compartment of shoulder
* Bruising
** As a manifestation of internal injury to the local vessels by trauma or fractures bone
* Decrease in range of motion
** Movement of the fractures limb will be painful if possible at all
* Tenderness
* Deformity
** Fractured bone deformity may be touchable in the internal side of the forearm if the fracture is displaced
In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the forearm. In polytrauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the [[compartment syndrome]], and the compartment pressures should be measured and monitored.


Image:
Physical examination of patients with  [[Boxer's fracture]] is usually remarkable for [[swelling]], [[tenderness]], [[Bruise|bruises]], [[ecchymosis]], [[deformity]] and restricted [[range of motion]] of the [[wrist]].


Boxers-fracture-002.jpg
=== Appearance of the Patient ===
* Patients with  [[Boxer's fracture]]  usually appears normal unless the patients had a high energy trauma causing the open wound fracture.


Image:
=== Vital Signs ===
* [[Pulse|Weak pulse]] may be seen when associated with [[polytrauma]].
* [[Hypotension|Low blood pressure]] with normal [[pulse pressure]] may be present due to [[compound fracture]] with [[Bleeding|blood loss]].
 
=== Skin ===
* Skin examination of patients with [[Boxer's fracture]]  includes:
** [[Bruise|Bruises]]
** [[Ecchymosis]]
 
=== HEENT ===
* HEENT examination of patients with [[Boxer's fracture]]  usually normal.
 
=== Neck ===
* Neck examination of patients with [[Boxer's fracture]] is usually normal
 
=== Lungs ===
* Pulmonary examination of patients with [[Boxer's fracture]]  usually normal
 
=== Heart ===
* Cardiovascular examination of patients with [[Boxer's fracture]]  usually normal
 
=== Abdomen ===
* Abdominal examination of patients with [[Boxer's fracture]] usually normal
 
=== Back ===
* Back examination of patients with [[Boxer's fracture]] usually normal
 
=== Genitourinary ===
* Genitourinary examination of patients with [[Boxer's fracture]]  usually normal
 
=== Neuromuscular ===
* Neuromuscular examination of patients with  [[Boxer's fracture]] is usually normal
* However, some patients may develop [[neuropraxia]] of the branch of the Ulnar nerve resulting in decreased sensation of thumb, index and middle finger.
 
==Laboratory Findings==
There is a limited laboratory tests useful in the diagnosis of bone fractures such as the [[Boxer's fracture]]. Meanwhile, aged men and women may have some abnormalities in their laboratory findings suggestive of osteoporosis.
 
Laboratory tests for the diagnosis of osteoporosis are:
* Complete blood count (CBC)
* Serum total calcium level
* Serum Ionized calcium level
* Serum phosphate level
* Serum alkaline phosphatase level
* Serum 25-(OH)-vitamin D level
 
==X Ray ==
The orthopedic surgeon should consider to have at least two radiographic projections (ie, anteroposterior [AP] and lateral) of the forearm. These show the fracture, the extent of displacement, and the extent of comminution. The orthopedic surgeon should pay serious attention toward finding any foreign bodies in open fractures and gunshot injuries. Also imperative is to include the elbow and wrist joint in the radiographs of [[Boxer's fracture]] to ensure that the wrist joint injuries are not missed.
 
<gallery perrow="3">
File:Boxer-fracture-12 (1).jpg| 5th metacarpal neck fracture consistent with a boxer fracture.
File:Boxer-fracture-12 (2).jpg| 5th metacarpal neck fracture consistent with a boxer fracture.
File:Boxer-fracture-12.jpg| 5th metacarpal neck fracture consistent with a boxer fracture.


Boxers-fracture-003.jpg


</gallery>
</gallery>


==Treatment==
==CT ==
These fractures are often angulated, and if severely so require pins to be put in place and realignment as well as the usual splinting. However, the prognosis on these fractures is generally good, with total healing time not exceeding 12 weeks. The first two weeks will show significantly reduced overall swelling with improvement in clenching ability showing up first. Ability to extend the fingers in all directions appears to improve more slowly. Hard casts are rarely required and soft casts or splints can be removed for brief periods of time to allow for activities such as showers and "airing out" the casted or splinted area so as to avoid skin rotting and permit cleansing of the casted or splinted area. Pain from this injury is generally very mild and rarely requires medications beyond over the counter drugs such as ibuprofen or acetaminophen. Muscle atrophy in isolated areas of 5 to 15 percent should be expected with a rehabilitation period of approximately 4 months given adequate therapy. In the mildest of cases, full rehabilitation status can be achieved within 3 to 4 months.
* CT-scan in the case of  the [[Boxer's fracture]]is the best modality if you can not have an exclusive diagnosis by X-ray itself can not be made.
 
==MRI ==
* Magnetic resonance imaging (MRI) is an expensive technique that should not be used routinely.
* MRI is a powerful diagnostic tool to assess the abnormalities of the bone, ligaments and soft tissues associated with the [[Boxer's fracture]], but it is known as a limited utility in radioulnar injuries and is not indicated in uncomplicated forearm fractures.
* Meanwhile, the MRI can be useful in in following mentioned evaluations:
* Evaluation of occult [[Bone fracture|fractures]]
* Evaluation of the post-traumatic or [[avascular necrosis]] of [[carpal bones]]
* Evaluation of [[tendons]]
* Evaluation of [[Median nerve|nerve]]
* Evaluation of [[carpal tunnel syndrome]]
 
==Other Imaging Findings==
There are no other imaging findings associated with [[Boxer's fracture]]
 
==Other Diagnostic Studies==
There are no other Diagnostic studies associated with  [[ Boxer's fracture]]
 
==Treatment ==
Immediate stabilization of patients is the first step. Then the radial fracture and the DRUJ stabilization is recommended in these cases. Open forearm fractures considered as a surgical emergency. [[Boxer's fracture]] occurs in younger patients who are skeletally immature; the normally they treated using a closed reduction and casting. Since closed reduction and cast application have led to unsatisfactory results. Then, Almost always the open reduction are necessary for the [[Boxer's fracture]]. There are controversies regarding the indications for intramedullary nailing of forearm fractures.
 
==Non-Operative Treatmen ==
* The first step in managing a patient with a fracture is to stabilize the patient if he/she is unstable due to blood loss, etc by giving them intravenous fluids and giving them some painkillers if the pain is severe.
* In children, the usual plan is to attempt closed reduction followed by cast immobilization. In adults, treatment with immobilization in a molded long arm cast can be used in those rare occasions of a non-displaced fracture of both bones of the forearm. If the fracture shifts in position, it may require surgery to put the bones back together.
* Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of the [[Boxer's fracture]]
* For all patients with [[Boxer's fracture]], a post-reduction true lateral [[Radiography|radiograph]] is suggested .
* Operative fixation is suggested in preference to [[Orthopedic cast|cast]] fixation for fractures with post-reduction radial [[shortening]] greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or step-off greater than 2 mm.
* Patients probably do not need to begin early wrist motion routinely after stable [[Bone fracture|fracture]] fixation.
* Adjuvant treatment of [[Boxer's Boxer's fracture]] with vitamin C is suggested for the prevention of disproportionate [[pain]]
* The medial epicondylar fractures should be immobilized for 7 days with patients elbow flexed at 90º, with the pronated forearm , and the flexed wrist at 30º for relaxing the common flexor-pronator muscle group. If more than 3 mm of displacement is present or the fragment is trapped in the medial joint, attempts at closed reduction often fail, and ORIF is necessary.
* Lateral epicondylar fractures should be immobilized for 7 days with patients elbow flexed at 90º, with the supinated forearm , and the extended wrist for relaxing the extensor muscles.
=== Complications of Non-surgical therapy ===
Failure of non-surgical therapy is common:
* Re-displacement to its original position even in a cast
* [[Stiffness]]
* Post traumatic [[osteoarthritis]] leading to wrist pain and loss of function
* Other risks specific to cast treatment include:
** Compression of the swollen arm causing [[compartment syndrome]]
** [[Reflex sympathetic dystrophy]] is a serious complication
** Stiffness is universal following a prolonged period of immobilization and swelling
 
==Surgery ==
Returning to the normal physical activity after [[Boxer's fracture]]can take weeks to months of therapy under supervision an orthopedist. Meanwhile, a physiotherapy can be helpful for patient to achieve the normal wrist and elbow function caused by the immobilisation. All adult [[Boxer's fracture]] should be considered to be treated with open reduction and internal fixation (ORIF).  
 
External fixation: For severe open fractures
Open reduction and internal fixation: For Boxer's fractures which depending on each patients condition the following may be needed:


For smaller angled [[fracture (bone)|fracture]]s most discomfort is alleviated by raising the fracture above the [[heart]], also if there is no cast warm water will relieve some of the pain. It is important that when the cast is removed that the hand is gently exercised by attempting the common functions of the hand. All advice has been given from fracture patients who first received treatment from an Orthopedic doctor, which in ideal cases should be consulted.
Ulnar nerve placement
Bone grafting
Osteotomy
Arthrodesis
=== Operation ===
* There are a variety of methods and implants useful to stabilize the  [[Boxer's fracture]], ranging from closed reduction and percutaneous pin fixation to the use of intra-medullary devices.
* However, the most common fixation methods to treat complex [[Boxer's fracture]] include [[external fixation]], and open reduction and internal fixation.


===Prevention===
=== External Fixation With or Without Percutaneous Pin Fixation ===
[[Boxing|Boxers]] and other [[Mixed martial arts|combat athletes]] routinely use [[hand wraps]] and [[boxing gloves]] to help stabilize the hand, greatly reducing pain and risk of injury during impact training such as working the [[punching bag|heavy bag]].
* [[Wrist]] spanning [[external fixation]] employs ligamentotaxis to restore and maintain length, alignment, and rotation of thumb bone.
* Reduction is typically obtained through closed or minimally open methods and preserves the [[Bone fracture|fracture]] biology.
* The addition of percutaneous pins enhances the ability to reduce and stabilize fracture fragments.
 
==== Complications of External Fixation ====
* Pin tract [[infection]]
* Injury to the [[Superficial branch of the radial nerve|superficial branch of the nerve]]
* [[Complex regional pain syndrome]]
 
=== Open reduction and internal fixation with plates and screws ===
* This is the most common type of surgical repair for  [[Boxer's fracture]]
* During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment.
* The bones held together with special screws and metal plates attached to the outer surface of the bone.
 
==== Complications of open reduction and internal fixation with plates and screws =====
* Infection
* Damage to nerves and blood vessels
* Synostosis
* Nonunion
 
=== Pain Management ===
Pain after an injury or surgery is a natural part of the healing process.
 
Medications are often prescribed for short-term pain relief after surgery or an injurysuch as:
* opioids
* non-steroidal anti-inflammatory drugs (NSAIDs)
* local anesthetics
 
=== Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive.  It is important to use opioids only as directed by doctor. ===
 
=== Interventions ===
The following options can be helpful for patients to rehabilitate after their fracture :
* Joints mobilization
* compression bandage
* Soft tissue massage
* Exercises and Activity modification
* Forearm taping
* Forearm bracing
 
== Postoperative Rehabilitation ==
* Complex  [[Boxer's fracture]] warrant individualized immobilization and rehabilitation strategies.
* Similarly, the addition of a thumb spica [[Orthopedic cast|cast]] or [[orthosis]] with positioning of the [[wrist]] in slight ulnar deviation for management of a [[comminuted]] radial column fracture may prevent loss of reduction. *Because most multifragmentary [[Boxer's fracture]] are the result of high-energy injuries, a prolonged period of [[wrist]] immobilization and [[Soft tissue|soft-tissue]] rest may be beneficial and has not been shown to affect clinical outcomes.
* The [[wrist]] is typically immobilized for 2 weeks post-operatively in a sugar tong [[Splint (medicine)|splint]] with neutral forearm rotation.
* At 6 weeks post-operatively, the wrist is placed into a removable orthosis, and active and passive range of motion (ROM) is initiated.
* Full weight bearing commences at approximately 3 months post-operatively after consolidation of the [[Bone fracture|fracture]] is noted on radiographs.
* The presence of varying degrees of [[hand]], [[wrist]], and [[elbow]] [[stiffness]] is inevitable and may result from poor [[pain]] control, lack of effort in controlled mobilization, [[edema]], concomitant ipsilateral [[Upper limb|upper extremity]] [[Bone fracture|fracture]]<nowiki/>s, or [[Peripheral nervous system|peripheral nerve]] injuries.
* Early stretching and mobilization of the intrinsic and extrinsic [[Tendon|tendons]] of the [[hand]] is important to prevent finger [[stiffness]].
* [[Edema]] control can be initiated with compression gloves, digital massage, and active and passive ROM of the [[hand]].
* A home [[Physical exercise|exercise]] program or outpatient occupational therapy is started immediately post-operatively to maintain full [[range of motion]] of the [[hand]] and limit the development of intrinsic muscle tightness
 
==Primary Prevention==
There are various preventive options to reduce the incidence of the [[Boxer's fracture]]
# Using forearm and wrist guards during practicing sports (skating, biking)
# Using forearm and wrist guards during driving motorbikes
# Avoid falls in elderly individuals
# Prevention and/or treatment of osteoporosis
# Healthy diet
 
==Secondary Prevention==
It should be noted that the Post-menopausal women specially older than the age of 65 are at the higher risk of [[osteoporosis]] consequently these type of patients at greater risk for the pathological [[Bone fracture|fractures]] .
 
So the [[Calcium]] and [[vitamin D]] supplementation play important role in increasing the [[Bone mineral density|bone mineral density (BMD]]) consequently decrease the risk of fracture in these type of patients. Also, avoiding excessive [[alcohol]] and quitting [[smoking]] play important role in this regard.
 
=== Detecting osteoporosis===
* [[Dual energy X-ray absorptiometry|DEXA]](dual-energy x-ray absorptiometry) scan
* Serum [[calcium]] and [[vitamin D]] levels
* [[Medical ultrasonography|Ultrasonography]] of the [[calcaneus]]
 
=== Pharmacological therapy ===
* The primary goal for the treatment of [[osteoporosis]] is to reduce longtime [[fracture]] risk in patients. Increasing [[Bone mineral density|bone mineral density (BMD)]] in response to the treatment is far less important than improvement of clinical aspects of [[osteoporosis]], i.e., [[Osteoporosis|osteoporotic]][[Bone fracture|fracture]]. Therefore, most of the [[drugs]] efficacy is measured by the extent they improve the [[fracture]] risk instead of increasing [[Bone mineral density|BMD]].
* During the treatment, if a single [[fracture]] happens, it does not necessarily indicate treatment failure or the need to be started on an alternative treatment or patient referral to a [[specialist]].
* [[Calcium]] and [[vitamin D]] supplementation have been found to be effective in reducing the long term [[Bone fracture|fracture]] risk, significantly. In order to suggest the people to use [[vitamin D]] and [[calcium]] [[supplements]], the [[physician]] needs to make sure that patient is not able to obtain the [[nutrients]] through the daily intake. The available supplemental ions of [[calcium]] include [[calcium carbonate]], [[Calcium citrate|calcium citrate,]] and [[vitamin D3]] in various [[Dosage form|dosage forms]].
 
=== Life style modifications===
* [[Exercise]]: Exercise promotes the [[mineralization]] of [[bone]] and [[bone]] accumulation particularly during growth. High impact exercise, in particular, has been shown to prevent the development of [[osteoporosis]]. However, it can have a negative effect on bone [[mineralization]] in cases of poor [[nutrition]], such as [[anorexia nervosa]] and [[celiac disease]].
* [[Nutrition]]: A [[diet]] high in [[calcium]] and [[vitamin D]] prevents [[bone loss]]. Patients at risk for [[osteoporosis]], such as persons with chronic [[steroid]] use are generally treated with [[vitamin D]] and [[calcium]] supplementation. In [[Kidney|renal]] disease, more active forms of [[vitamin D]], such as 1,25-dihydroxycholecalciferol or [[calcitriol]] are used; as the kidney cannot adequately generate [[calcitriol]] from [[calcidiol]] (25-hydroxycholecalciferol), which is the storage form of [[vitamin D]].
* By quitting [[smoking]], [[osteoporosis]] as well as other diseases can be prevented.
* Avoiding excessive [[alcohol]] intake or drinking only in moderation.
{{WH}}
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==See also==
* [[Rolando fracture]]
* [[Boxer's fracture]]
* [[Gamekeeper's thumb]]


==References==
==References==
Line 51: Line 539:


==External links==
==External links==
* http://www.med.umich.edu/1libr/sma/sma_meta5car_art.htm
* {{GPnotebook|1288699906}}
* http://www.wheelessonline.com/ortho/boxers_fracture_metacarpal_neck_1
* {{WhoNamedIt|synd|3263|Bennett's fracture}}
* http://www.med.wayne.edu/diagRadiology/TF/MS/MS18.html
* http://www.wheelessonline.com/ortho/bennetts_fracture_dislocation


[[Category:Physiology]]
{{Fractures}}
{{WikiDoc Sources}}
 
[[Category:Bone fractures]]
[[Category:Fractures]]
[[Category:Fractures]]
 
[[Category:Orthopedics]]
{{Fractures}}
[[Category:Radiology]]
{{Surgery-stub}}
[[Category:Injuries of wrist and hand]]
{{WH}}
{{WS}}

Latest revision as of 20:40, 29 July 2020

Boxer's fracture
ICD-10 S42.2-S42.4
ICD-9 812
eMedicine emerg/199  orthoped/271 orthoped/199

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou[2].

Overview

The Boxer's fracture is a fracture of the base of the 5th metacarpal neck and known as the most common metacarpal fracture . The early diagnosis and treatment are imperative to prevent loss of function of this highly mobile human joint system.

Historical Perspective

There are no reliable information regarding the historical perspective of the Boxer's fracture.

Causes

The main etiology of the Boxer's fracture is an axial load to the 5th metacarpal. Usually its a result of a direct force using a clenched fist against a solid surface area such as human face, wall, or tree.

As a person age, two factors cause higher risk of fractures:

  • Weaker bones
  • Greater risk of falling

Stress fractures as a common causes of fractures can be found due to the repeated stresses and strains. Importantly children having more physically active lifestyles than adults, are also prone to fractures. People with any underlying diseases such as osteoporosis, infection, or a tumor affecting their bones having a higher risk of fractures. As mentioned in previous chapters, this type of fracture is known as a pathological fracture. Stress fractures, which result from repeated stresses and strains, commonly found among professional sports people, are also common causes of fractures.

Life-threatening Causes

Common Causes

Common causes of Boxer's fracture may include:

  • Direct Trauma (Fall on an outstretched hand)

Less Common Causes

Less common causes of Boxer's fracture include conditions that predisposes to fracture:

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal/Orthopedic Osteoporosis and osteopenia.
Neurologic No underlying causes
Nutritional/Metabolic Osteoporosis and osteopenia.
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma Falling of car accident
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

List the causes of the disease in alphabetical order:

Pathophysiology

Mechanism

The Boxer's fracture is caused by a falling or any types of trauma affecting the patients hand and specifically the 5th metacarpal joint. The form and severity of this fracture depends on the position of the hand at the moment of hitting the ground. The width of this mentioned angle affects the localization of the fracture.

Pathophysiology

Its known that the Boxer's fracture in normal healthy adults can be caused due to the high energy load such as fighting using fist to fight.

But it should be noted that the most important Risk factors for insufficiency fractures is chronic metabolic disease such as steoporosis, osteopenia, eating-disordered behavior, higher age, prolonged corticosteroid usage, female gender, lower BMI, history of a recent falling, and prior fracture.

  • The pattern of bone fracture and severity of injury depends on variety of factors such as:
    • Patients age
    • Patients Weight
    • Patients past medical history specifically any bone diseases affecting the quality of bone (such as osteoporosis, malignancies)
    • Energy of trauma
    • Bone quality
    • Position of the specific organ during the trauma
  • The below-mentioned processes cause decreased bone mass density:

Differentiating Boxer's fracture from other Diseases

In the orthopedic medicine its important to know that the forearm fracture should be evaluated using radiography for both confirming diagnosis and also for evaluating the surrounding tissues. Other injuries such as possible hand fracture-dislocation; radial head or coronoid fractures or lateral collateral ligament injury. If the mechanism of injury suggests particularly low energy then the Osteoporosis should be considered. The pathological Fractures occurring in a bone with a tumor or Paget's disease) are rare but possible.

Also it should be noted that the both bone fractures can be complicated by acute compartment syndrome of the forearm. Signs suggesting compartment syndrome are pain on extension of digits, and marked edema.

As another important fact in orthopedic fracture is if both-bone fractures were found in pediatric which is common after accidental trauma, but it may also be the due to the of child abuse; and in these cases a careful attention and evaluation should be considered if a child abuse is suspected

Differential Diagnoses for the Boxer's fracture:

  • Boxer knuckle
  • Bennett's fracture
  • Rolando's fracture
  • Pseudo-Bennett fracture

Epidemiology and Demographics

The total fractures of the thumb are common in children (22% of hand fractures affecting the in the thumb) and the elderly (20% of hand fractures affecting the in the thumb) population.

Risk Factors

There are different risk factors that predispose patient for the Boxer's fracture that include:

  • High-risk contact sports
  • Higher age (elderly adults are higher prone to such fractures)
  • Reduced bone density (osteoporosis)
  • Direct blow
  • Road / traffic accidents
  • Falling on an outstretched hand with the forearm pronated
  • Direct trauma to the arm/forearm
  • Taking part in any rough or high-impact sport
  • Street fights, gunshot wounds, and domestic violence, may also cause the Boxer's fracture
  • Road traffic accidents.

Classification

Classification of the first metacarpal fractures
Name Type Features
Oblique Extra-articular • oblique fracture line not involving the articular surface
Transverse Extra-articular
• a pure transverse fracture line not involved the articular surface
Bennett Intra-articular • intra-articular fracture with a palmar radial fragment
Rolando Intra-articular
 • Y or T shaped complete intra-articular fracture
Comminuted Intra-articular • severely comminuted complete intra-articular fracture  

Screening

Osteoporosis is an important risk factor for human affecting human bone especially in men with the age of older than 50 years old and postmenopausal and women.

Based on the US Preventive Services Task Force (USPSTF) there are three groups of patients need to be screened for the osteoporosis:

  • ·       Men with no history of osteoporosis
  • ·       Women with the age of 65≤ year old, with no previous history of pathological fracture due to the osteoporosis
  • ·       Women with the age of <65 years, with 10-year fracture risk of not less than a 65-year-old white woman (who has not any other risk factor)

Accordingly women older than age of 50 are the main target for the osteoporosis screening. There is no specific recommendation to screen men for the osteoporosis.

The USPSTF recommendations from 2002 included:

Meanwhile, there are two major modalities for the osteoporosis screening:

  1. ·       Dual energy x-ray absorptiometry (DXA) of the hip and lumbar spine bones
  2. ·       Quantitative ultrasonography of the calcaneus

*It should be noted of the two above mentioned modalities for screening the ultrasonograhy is preferred to the DXA due to its lower cost, lower ionizing radiation, more availability.

After the primary evaluation of the osteoporosis, the further evaluation are required in some cases such as:

·       Women with normal bone density or mild osteopenia: T-score of greater than −1.50 – should have screening for 15 years.

·       Women with moderate osteopenia: T-score of −1.50 to −1.99 – should have screening for 5 years.

·       Women with advanced osteopenia: T-score of −2.00 to −2.49 - should have screening for 1 year.

Natural History, Complications and Prognosis

Natural History

In cases with untreated Boxer's fracture the malunion and deformity of arm can be occurred.

Complications

The overall complication rate in the treatment of Boxer's fracture were found in around 40% of cases:

  1. Neurovascular compromise: such as Ulna nerve damage
  2. Compartment syndrome
  3. Chronic disability of the DRUJ
  4. Physeal Injury
  5. Malunion of the radius
  6. Nonunion
  7. Infection
  8. Refracture following plate removal
  9. Posterior interosseois nerve (PIN) injury.
  10. Instability of the DRUJ
  11. Loss of Motion (Stiffness)
  12. Posttraumatic Arthritis
  13. Heterotopic Ossification

Prognosis

The prognosis of the Boxer's fracture is most closely related to the amount of energy and the main direction of the trauma. High-energy injuries leading to a poor outcome due to the comminution, articular surface damage, and extensive soft-tissue injury. But the good prognosis can be found in low-energy injuries with simple fracture patterns and limited soft-tissue involvement which the anatomic restoration of the joint surface and reestablishment are stable, the outcome is routinely good, especially in low-energy injuries with simple fracture patterns and limited soft-tissue involvement.

Diagnosis

The diagnosis of a Boxer's fracture should be confirmed using a radiographic examination.

History and Symptoms

The related signs and symptoms include:

  • Deformity
  • Skin lacerations
  • Weak pulse
  • Open fractures
  • Bruising
  • Swelling
  • Stiffness
  • Inability to move
  • Pain in touch
  • Loss of function of the forearm
  • Difficulties in detection of pulses
  • Radial nerve damage

In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the forearm. In MULTI-trauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the compartment syndrome, and the compartment pressures should be measured and monitored. Normally the pain and soft-tissue swelling are found at the injury site (at the wrist joint). This injury should be confirmed using a radiographic evaluations. Also, patients may loss the pinch mechanism between their thumb and their index finger which can be due to the paralysis of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP).

Physical Examination

The related signs and symptoms include:

  • Edema of the shoulder
    • Most of the time the edema will be a non-pitting edema
    • Depends on the edema extent, it may even lead to compartment syndrome in the anterior and internal compartment of shoulder
  • Bruising
    • As a manifestation of internal injury to the local vessels by trauma or fractures bone
  • Decrease in range of motion
    • Movement of the fractures limb will be painful if possible at all
  • Tenderness
  • Deformity
    • Fractured bone deformity may be touchable in the internal side of the forearm if the fracture is displaced

In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the forearm. In polytrauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the compartment syndrome, and the compartment pressures should be measured and monitored.

Physical examination of patients with Boxer's fracture is usually remarkable for swelling, tenderness, bruises, ecchymosis, deformity and restricted range of motion of the wrist.

Appearance of the Patient

  • Patients with Boxer's fracture usually appears normal unless the patients had a high energy trauma causing the open wound fracture.

Vital Signs

Skin

HEENT

Neck

Lungs

Heart

Abdomen

Back

Genitourinary

Neuromuscular

  • Neuromuscular examination of patients with Boxer's fracture is usually normal
  • However, some patients may develop neuropraxia of the branch of the Ulnar nerve resulting in decreased sensation of thumb, index and middle finger.

Laboratory Findings

There is a limited laboratory tests useful in the diagnosis of bone fractures such as the Boxer's fracture. Meanwhile, aged men and women may have some abnormalities in their laboratory findings suggestive of osteoporosis.

Laboratory tests for the diagnosis of osteoporosis are:

  • Complete blood count (CBC)
  • Serum total calcium level
  • Serum Ionized calcium level
  • Serum phosphate level
  • Serum alkaline phosphatase level
  • Serum 25-(OH)-vitamin D level

X Ray

The orthopedic surgeon should consider to have at least two radiographic projections (ie, anteroposterior [AP] and lateral) of the forearm. These show the fracture, the extent of displacement, and the extent of comminution. The orthopedic surgeon should pay serious attention toward finding any foreign bodies in open fractures and gunshot injuries. Also imperative is to include the elbow and wrist joint in the radiographs of Boxer's fracture to ensure that the wrist joint injuries are not missed.

  • 5th metacarpal neck fracture consistent with a boxer fracture.
    5th metacarpal neck fracture consistent with a boxer fracture.
  • 5th metacarpal neck fracture consistent with a boxer fracture.
    5th metacarpal neck fracture consistent with a boxer fracture.
  • 5th metacarpal neck fracture consistent with a boxer fracture.
    5th metacarpal neck fracture consistent with a boxer fracture.

CT

  • CT-scan in the case of the Boxer's fractureis the best modality if you can not have an exclusive diagnosis by X-ray itself can not be made.

MRI

  • Magnetic resonance imaging (MRI) is an expensive technique that should not be used routinely.
  • MRI is a powerful diagnostic tool to assess the abnormalities of the bone, ligaments and soft tissues associated with the Boxer's fracture, but it is known as a limited utility in radioulnar injuries and is not indicated in uncomplicated forearm fractures.
  • Meanwhile, the MRI can be useful in in following mentioned evaluations:
  • Evaluation of occult fractures
  • Evaluation of the post-traumatic or avascular necrosis of carpal bones
  • Evaluation of tendons
  • Evaluation of nerve
  • Evaluation of carpal tunnel syndrome

Other Imaging Findings

There are no other imaging findings associated with Boxer's fracture

Other Diagnostic Studies

There are no other Diagnostic studies associated with Boxer's fracture

Treatment

Immediate stabilization of patients is the first step. Then the radial fracture and the DRUJ stabilization is recommended in these cases. Open forearm fractures considered as a surgical emergency. Boxer's fracture occurs in younger patients who are skeletally immature; the normally they treated using a closed reduction and casting. Since closed reduction and cast application have led to unsatisfactory results. Then, Almost always the open reduction are necessary for the Boxer's fracture. There are controversies regarding the indications for intramedullary nailing of forearm fractures.

Non-Operative Treatmen

  • The first step in managing a patient with a fracture is to stabilize the patient if he/she is unstable due to blood loss, etc by giving them intravenous fluids and giving them some painkillers if the pain is severe.
  • In children, the usual plan is to attempt closed reduction followed by cast immobilization. In adults, treatment with immobilization in a molded long arm cast can be used in those rare occasions of a non-displaced fracture of both bones of the forearm. If the fracture shifts in position, it may require surgery to put the bones back together.
  • Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of the Boxer's fracture
  • For all patients with Boxer's fracture, a post-reduction true lateral radiograph is suggested .
  • Operative fixation is suggested in preference to cast fixation for fractures with post-reduction radial shortening greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or step-off greater than 2 mm.
  • Patients probably do not need to begin early wrist motion routinely after stable fracture fixation.
  • Adjuvant treatment of Boxer's Boxer's fracture with vitamin C is suggested for the prevention of disproportionate pain
  • The medial epicondylar fractures should be immobilized for 7 days with patients elbow flexed at 90º, with the pronated forearm , and the flexed wrist at 30º for relaxing the common flexor-pronator muscle group. If more than 3 mm of displacement is present or the fragment is trapped in the medial joint, attempts at closed reduction often fail, and ORIF is necessary.
  • Lateral epicondylar fractures should be immobilized for 7 days with patients elbow flexed at 90º, with the supinated forearm , and the extended wrist for relaxing the extensor muscles.

Complications of Non-surgical therapy

Failure of non-surgical therapy is common:

  • Re-displacement to its original position even in a cast
  • Stiffness
  • Post traumatic osteoarthritis leading to wrist pain and loss of function
  • Other risks specific to cast treatment include:

Surgery

Returning to the normal physical activity after Boxer's fracturecan take weeks to months of therapy under supervision an orthopedist. Meanwhile, a physiotherapy can be helpful for patient to achieve the normal wrist and elbow function caused by the immobilisation. All adult Boxer's fracture should be considered to be treated with open reduction and internal fixation (ORIF).

External fixation: For severe open fractures Open reduction and internal fixation: For Boxer's fractures which depending on each patients condition the following may be needed:

Ulnar nerve placement Bone grafting Osteotomy Arthrodesis

Operation

  • There are a variety of methods and implants useful to stabilize the Boxer's fracture, ranging from closed reduction and percutaneous pin fixation to the use of intra-medullary devices.
  • However, the most common fixation methods to treat complex Boxer's fracture include external fixation, and open reduction and internal fixation.

External Fixation With or Without Percutaneous Pin Fixation

  • Wrist spanning external fixation employs ligamentotaxis to restore and maintain length, alignment, and rotation of thumb bone.
  • Reduction is typically obtained through closed or minimally open methods and preserves the fracture biology.
  • The addition of percutaneous pins enhances the ability to reduce and stabilize fracture fragments.

Complications of External Fixation

Open reduction and internal fixation with plates and screws

  • This is the most common type of surgical repair for Boxer's fracture
  • During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment.
  • The bones held together with special screws and metal plates attached to the outer surface of the bone.

Complications of open reduction and internal fixation with plates and screws =

  • Infection
  • Damage to nerves and blood vessels
  • Synostosis
  • Nonunion

Pain Management

Pain after an injury or surgery is a natural part of the healing process.

Medications are often prescribed for short-term pain relief after surgery or an injurysuch as:

  • opioids
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • local anesthetics

Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive.  It is important to use opioids only as directed by doctor.

Interventions

The following options can be helpful for patients to rehabilitate after their fracture :

  • Joints mobilization
  • compression bandage
  • Soft tissue massage
  • Exercises and Activity modification
  • Forearm taping
  • Forearm bracing

Postoperative Rehabilitation

  • Complex Boxer's fracture warrant individualized immobilization and rehabilitation strategies.
  • Similarly, the addition of a thumb spica cast or orthosis with positioning of the wrist in slight ulnar deviation for management of a comminuted radial column fracture may prevent loss of reduction. *Because most multifragmentary Boxer's fracture are the result of high-energy injuries, a prolonged period of wrist immobilization and soft-tissue rest may be beneficial and has not been shown to affect clinical outcomes.
  • The wrist is typically immobilized for 2 weeks post-operatively in a sugar tong splint with neutral forearm rotation.
  • At 6 weeks post-operatively, the wrist is placed into a removable orthosis, and active and passive range of motion (ROM) is initiated.
  • Full weight bearing commences at approximately 3 months post-operatively after consolidation of the fracture is noted on radiographs.
  • The presence of varying degrees of hand, wrist, and elbow stiffness is inevitable and may result from poor pain control, lack of effort in controlled mobilization, edema, concomitant ipsilateral upper extremity fractures, or peripheral nerve injuries.
  • Early stretching and mobilization of the intrinsic and extrinsic tendons of the hand is important to prevent finger stiffness.
  • Edema control can be initiated with compression gloves, digital massage, and active and passive ROM of the hand.
  • A home exercise program or outpatient occupational therapy is started immediately post-operatively to maintain full range of motion of the hand and limit the development of intrinsic muscle tightness

Primary Prevention

There are various preventive options to reduce the incidence of the Boxer's fracture

  1. Using forearm and wrist guards during practicing sports (skating, biking)
  2. Using forearm and wrist guards during driving motorbikes
  3. Avoid falls in elderly individuals
  4. Prevention and/or treatment of osteoporosis
  5. Healthy diet

Secondary Prevention

It should be noted that the Post-menopausal women specially older than the age of 65 are at the higher risk of osteoporosis consequently these type of patients at greater risk for the pathological fractures .

So the Calcium and vitamin D supplementation play important role in increasing the bone mineral density (BMD) consequently decrease the risk of fracture in these type of patients. Also, avoiding excessive alcohol and quitting smoking play important role in this regard.

Detecting osteoporosis

Pharmacological therapy

Life style modifications

Template:WH Template:WS

See also

References

External links

Template:Fractures Template:WikiDoc Sources

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