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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

FEATURE ARTICLE FREE

The Boxer's Fracture: Splint Immobilization


Is Not Necessary
John C. Dunn, MD; Nicholas Kusnezov, MD; Justin D. Orr, MD; Mark Pallis, DO; Justin S. Mitchell,
DO

Orthopedics
May/June 2016 - Volume 39 Issue 3: 188-192
Posted March 29, 2016
DOI: 10.3928/01477447-20160315-05

Abstract
Fractures of the fifth metacarpal neck, or boxer's fractures, are common, particularly among
young men. Because of the high frequency of this injury, there is a considerable range of
treatment options. The purpose of this systematic review was to determine whether reduction
and splint or cast immobilization is necessary for fractures of the fifth metacarpal neck. The
authors conducted a systematic review of all published studies that randomized these fractures to
cast immobilization vs treatment with soft wrap without reduction. Cast immobilization is not
superior to soft wrap without reduction in most cases. The study found that reduction and cast
immobilization is not necessary for boxer's fractures. [Orthopedics. 2016; 39(3):188192.]

Fractures of the fifth metacarpal neck, or boxer's fractures, are common, accounting for 20% of all
hand fractures.13 These injuries are most often sustained while striking an object with a closed fist
during impulsive periods,4 during fights,5 or after episodes of alcohol consumption.69 Although
these fractures are typically treated nonoperatively, most often with closed reduction and splint
immobilization,1012 there is concern that residual angulation at the fifth metacarpal neck may leave
patients with discomfort and cosmetic complaints.13,14 The proposed limit of fracture angulation to
minimize functional deficit is 30, without shortening or rotational deformity.15

However, prospective, randomized studies have shown that regardless of fracture angulation or
treatment method, adequate short-term1620 and long-term21 outcomes are achieved. The current
comprehensive systematic review of all available prospective, randomized studies compares
reduction and splint immobilization vs soft wrap without reduction of boxer's fractures. This study
demonstrates that there is no clear benefit to reduction and splint immobilization of boxer's
fractures.

Materials and Methods


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Literature Search
A systematic review of the literature was performed. The following search terms were queried in
PubMed, EMBASE, and Medline for the time period between 1960 and 2015: metacarpal neck
fracture*, boxer's fracture*, and subcapital metacarpal*. Two independent reviewers (J.C.D.,
N.K.) assessed the methodology and quality of each study. Homogeneous data were extracted
from studies that met the inclusion and exclusion criteria, and frequency-weighted means were
generated. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
diagram guided the study selection ( www.prisma-statement.org).

Inclusion and Exclusion Criteria


The inclusion criteria were as follows: (1) prospective, randomized design; (2) treatment of
metacarpal neck fractures; and (3) 2 treatment groups involving splinting vs soft wrap. Soft
wrap techniques in this study included buddy taping or soft wrap. Either self-adherent wrap21 or
silk tape16 was used for soft wrap, and all of these techniques are referred to as wrap for
simplicity.

The exclusion criteria were as follows: (1) non-English-language translation22; (2) any review,
technique article, biomechanical study, or case series without a control group; (3) any study with
unclear methods1; (4) operative management; and (5) any study that included a fracture brace in
lieu of a splint (Figure).23

Figure:

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Inclusion
and
exclusion
criteria.

If an abstract met the inclusion and exclusion criteria, the authors reviewed the entire text to
verify qualification. In addition, they manually reviewed all references from all studies that met
the inclusion and exclusion criteria to generate a list of qualifying studies not identified in the
electronic searches. The authors met and conferred at this point. There were no discrepancies
between their findings.

Data Extraction and Analysis


Study design, demographic variables (Table 1), outcomes (Table 2), and complications (Table
3) were extracted and analyzed. Two authors (J.C.D., N.K.) independently extracted the data,
then conferred and compiled the data, correcting any discrepancies. Reported outcomes varied
between studies. To account for the heterogeneity, Table 2 reports which outcomes specific
authors used and which treatment method, either splint or wrap, was found to be superior.

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Table 1:
Demographics, Study
Size, and Basic
Treatment
Characteristics

Table 2:
Outcomes
of
Fracture
Treatment

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Table 3:
Complications
of Fracture
Treatment

Results
The search resulted in 50 potentially eligible studies; only 5 studies met the inclusion and
exclusion criteria. All studies were prospective, randomized, Level I therapeutic studies with
greater than 80% follow-up (Figure). In total, 215 patients with an average age of 28 years were
followed for an average of 13 months. Of these, 106 were randomized to the splint group and
109 were randomized to the soft wrap group (Table 1). The splint group did not receive a
reduction in 4 of the 5 studies.1619 In these studies, the exclusion criteria of dorsal angulation,
or the maximum angulation without a reduction attempt, was 50 to 70 (average, 59). All
splinted patients were placed in the intrinsic plus position.

Outcomes of the 2 cohorts were cumulatively similar across all studies (Table 2). Braakman et
al16 conducted a prospective, randomized study of 48 fifth metacarpal fractures with 6-month
follow-up. Half of the patients were randomized to immobilization and half were randomized to
buddy taping. In all, only 4 patients had a reduction: 2 for excessive angulation and 2 for a
rotational deformity. At 1 week, 4 weeks, and 3 months, the wrap group had better range of
motion (ROM). By 6 months, ROM between the 2 groups was equivalent. Similarly, pulling
strength, pronation strength, supination strength, and torque strength were better for the wrap
group at 1 week and 4 weeks. There was a slight loss in reduction in all 4 patients who had a
reduction by 1 week. Initial fracture angulation did not correlate with outcomes (Table 2).

Statius Muller et al17 followed a series of 35 boxer's fractures for 12 weeks. Fifteen were
randomized to plaster immobilization and 20 were randomized to a pressure dressing and
immediate ROM. At 6 and 12 weeks, there was no difference between the groups in terms of
metacarpophalangeal joint (MCPJ) ROM, pain, and overall satisfaction (Table 2).
18
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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

McMahon et al18 treated 42 patients with boxer's fractures, randomizing half to splints and half
to a compression dressing. At weeks 2 and 3, treatment favored the wrap cohort in terms of
ROM and swelling (Table 2).

Hansen and Hansen19 randomized 85 patients with boxer's fractures to treatment with either a
splint, a wrap, or a soft brace. Excluding the brace patients, the wrap cohort had improved
tenderness and MCPJ movement at 4 weeks. However, the splint group had 10 of additional
metacarpophalangeal joint ROM at 3 months. The groups were equally satisfied at the
conclusion of treatment (Table 2).

Kuokkanen et al20 randomized 29 patients with boxer's fractures to closed reduction with splint
vs no reduction and soft wrap with immediate ROM. At 4 weeks, the wrap had improved
metacarpophalangeal joint ROM and grip strength. Although grip strength remained superior in
the wrap cohort at 3 months, ROM was equivalent between the 2 groups. A reduction and splint
did not improve the range of angulation from the initial injury. Furthermore, it is worth noting
that this study was randomized; however, the wrap group had a significantly higher prereduction
fracture angulation (Table 2).

In the current study, the complications between the 2 groups were equivalent (Table 3). Whereas
several studies reported no complications, one study reported that approximately one-third of
both the splint and wrap cohorts had some degree of residual symptoms at 3 months.16 Statius
Muller et al17 reported that only 1 of 15 patients in the splint group and 1 of 20 patients in the
wrap group did not return to work at 6 weeks.

Discussion
The key finding of the current study is that there is no benefit to reduction and splint
immobilization of closed boxer's fractures with initial angulation of less than 70. In fact, using
soft wrap without reduction was generally favored in terms of MCPJ ROM,16,1820 strength,16,20
and swelling.19 Outcomes were generally equivalent in terms of pain17 and tenderness,19
fracture healing,20 patient satisfaction,17,19 and return to work.17

In the current study, the range of dorsal angulation that was accepted without reduction and
placed in a soft wrap varied from 50 to 70 (Table 1). The degree of dorsal angulation for a
closed boxer's fracture may not correlate with outcome.8,24 An analysis of boxer's fractures
separated into those with dorsal angulation above 30 and those below 30 demonstrated no
association with functional results.8 A prospective case series of boxer's fractures with
angulation up to 75 treated with buddy taping alone without reduction exhibited no adverse

21
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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

outcomes.21 Patients in this series had no loss in grip strength, 100% of fractures healed with no
change in fracture angulation, and median Disabilities of the Arm, Shoulder and Hand (DASH)
score was 0 at 3 years. Although the experimental group in this review was treated with a soft,
compressive wrap, buddy taping is an alternative method for boxer's fracture treatment in place
of a splint. It is hypothesized that buddy taping prevents rotational deformity.16

The current study established that reduction and splint immobilization are not superior to a soft
wrap or buddy tape (Table 2). In a similar systematic review of boxer's fractures, Poolman et
al25 found no superior method of fracture immobilization. Outcomes were at least equivalent in
the short term, and long-term outcomes of wrapping metacarpal fractures are excellent as well.21
In addition, obtaining long-term outcomes for these injuries is especially difficult. Hansen and
Hansen19 did not attempt a return-to-work analysis in their cohort because so many of their
patients were unemployed, nonworking, or students. In another prospective analysis of boxer's
fractures, Bansal and Craigen26 also had poor follow-up. The initial 40 patients with a boxer's
fracture were treated with reduction and splint immobilization; however, only half of the
patients returned for the follow-up visit. The second cohort included 38 patients who were
treated by buddy taping the fourth and fifth fingers. In this cohort, only 2 patients returned to
clinic. Despite the poor follow-up, the buddy taping group returned to work over 2 weeks before
the immobilization group (2.7 vs 5 weeks). In addition, the 2 groups had equivalent DASH
scores at 12 weeks.26

Although the subjective outcomes in the treatment of boxer's fractures are equivalent between
reduction and splint vs soft wrap, the radiographic outcomes were not well controlled for in the
current analysis (Table 2). However, one study noted no difference between the groups in mean
radiographic angulation,18 and another reported no difference in union rate.20 Furthermore,
some authors do not advocate ordering lateral radiographs in the follow-up period for these
fractures.27 Another study of 200 boxer's fractures demonstrated equivalent residual
radiographic dorsal angulation at 4 weeks post-injury in the treatment group that underwent
closed reduction and the group that did not.28

No major complications were identified in the current study (Table 3). There have been reports
of skin necrosis after splinting,29,30 but no cases were found in the current analysis. Both return
to work18 and incidence of residual symptoms (approximately one-third)18 were equivalent
between the 2 cohorts.

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This study has limitations. It included a limited number of patients with inconsistent and
irregular follow-up. Each study used different outcome variables, making it impossible to
combine data. In the future, a well-powered prospective, randomized study with close follow-
up, including specific outcome measures, should be conducted. However, despite these
shortcomings, to the authors' knowledge this is the most complete review of nonoperative
management of boxer's fractures.

Conclusion
Given the reasonable short- and long-term outcomes of wrapping boxer's fractures without
reduction,11,1621,25,28 it is likely that reduction with immobilization of these fractures is
unnecessary. For fifth metacarpal neck fractures with up to 70 apex dorsal angulation and
without a rotational deformity, the best available evidence suggests that a soft wrap with buddy
taping the fourth and fifth digits without reduction yields equivalent results to closed reduction
and splint treatment.

References
1. Hunter JM, Cowen NJ. Fifth metacarpal fractures in a compensation clinic population: a
report on one hundred and thirty-three cases. J Bone Joint Surg Am. 1970; 52(6):11591165.

2. Nakashian MN, Pointer L, Owens BD, Wolf JM. Incidence of metacarpal fractures in the US
population. Hand (N Y). 2012; 7(4):426430. doi:10.1007/s11552-012-9442-0 [CrossRef]

3. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the
United States. J Hand Surg Am. 2001; 26(5):908915. doi:10.1053/jhsu.2001.26322
[CrossRef]

4. Kural C, Alkas L, Tuzun S, Centinus E, Ugras AA, Alkas M. Anger scale and anger types of
patients with fifth metacarpal neck fractures. Acta Orthop Traumatol Turc. 2011; 45(5):312
315.

5. Greer MA. Incidence of metacarpal fractures in U.S. soldiers stationed in South Korea. J
Hand Ther. 2008; 21(2):137141. doi:10.1197/j.jht.2007.08.017 [CrossRef]

6. Trybus M, Lorkowski J, Brongel L, Hladki W. Causes and consequences of hand injuries. Am


J Sur. 2006; 192(1):5257. doi:10.1016/j.amjsurg.2005.10.055 [CrossRef]

7. Gudmundsen TE, Borgen L. Fractures of the fifth metacarpal. Acta Radiol. 2009; 50(3):296
300. doi:10.1080/02841850802709201 [CrossRef]

8. Ozturk I, Erturer E, Sahin F, et al. Effects of fusion angle on functional results following non-
operative treatment for fracture of the neck of the fifth metacarpal. Injury. 2008; 39(12):1464
1466. doi:10.1016/j.injury.2008.03.016 [CrossRef]

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

9. Winter M, Balaguer T, Bessiere C, Carles M, Lebreton E. Surgical treatment of the boxer's


fracture: transverse pinning versus intramedullary pinning. J Hand Surg Eur Vol. 2007;
32(6):709713. doi:10.1016/j.jhse.2007.07.011 [CrossRef]

10. Stern PJ. Fractures of metacarpals and phalanges. In: Hotckiss RN, Pederson WC, Wolfe
SW, Green DP, eds. Green's Operative Hand Surgery. Vol 1. 5th ed. New York, NY: Churchill
Livingstone; 2005.

11. Theeuwen GA, Lemmens JA, van Niekerk JL. Conservative treatment of boxer's fracture: a
retrospective analysis. Injury. 1991; 22(5):394396. doi:10.1016/0020-1383(91)90103-L
[CrossRef]

12. Westbrook AP, Davis TR, Armstrong D, Burke FD. The clinical significance of malunion of
fractures of the neck and shaft of the little finger metacarpal. J Hand Surg Eur Vol. 2008;
33(6):732739. doi:10.1177/1753193408092497 [CrossRef]

13. Ali A, Hamman J, Mass DP. The biomechanical effects of angulated boxer's fractures. J Hand
Surg Am. 1999; 24(4):835844. doi:10.1053/jhsu.1999.0835 [CrossRef]

14. McKerrell J, Bowen V, Johnston G, Zondervan J. Boxer's fractures: conservative or operative


management?J Trauma. 1987; 27(5):486490. doi:10.1097/00005373-198705000-00005
[CrossRef]

15. Prokop A, Helling HJ, Kulus S, Rehm KE. Conservative treatment of metacarpal fracture [in
German]. Kongressbd Dtsch Ges Chir Kongr. 2002; 119:532535.

16. Braakman M, Oderwald EE, Haentjens MH. Functional taping of fractures of the 5th
metacarpal results in a quicker recovery. Injury. 1998; 29(1):59. doi:10.1016/S0020-
1383(97)00106-X [CrossRef]

17. Statius Muller MG, Poolman RW, von Hoogstraten MJ, Steller EP. Immediate mobilization
gives good results in boxer's fractures with volar angulation up to 70 degrees: a prospective
randomized trial comparing immediate mobilization with cast immobilization. Arch Orthop
Trauma Surg. 2003; 123(10):534537. doi:10.1007/s00402-003-0580-2 [CrossRef]

18. McMahon PJ, Woods DA, Burge PD. Initial treatment of closed metacarpal fractures: a
controlled comparison of compression glove and splintage. J Hand Surg Br. 1994;
19(5):597600. doi:10.1016/0266-7681(94)90123-6 [CrossRef]

19. Hansen PB, Hansen TB. The treatment of fractures of the ring and little metacarpal necks: a
prospective randomized study of three different types of treatment. J Hand Surg Br. 1998;
23(2):245247. doi:10.1016/S0266-7681(98)80186-1 [CrossRef]

20. Kuokkanen HO, Mulari-Keranen SK, Niskanen RO, Haapala JK, Korkala OL. Treatment of
subcapital fractures of the fifth metacarpal bone: a prospective randomised comparison
between functional treatment and reposition and splinting. Scand J Plast Reconstr Surg
Hand Surg. 1999; 33(3):315317. doi:10.1080/02844319950159299 [CrossRef]

21. van Aaken J, Kampfen S, Berli M, Fritschy D, Della Santa D, Fusetti C. Outcome of boxer's
fractures treated by a soft wrap and buddy taping: a prospective study. Hand (N Y). 2007;

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

2(4):212217. doi:10.1007/s11552-007-9054-2 [CrossRef]

22. Poulsen MB, Hansen TB, Bang DM. Treatment of subcapital fractures of the 4th and the 5th
metacarpus: a clinical trial of the results after treatment without immobilization and reposition
and a study of the treatment of these fractures at casualty departments in Denmark [in
Danish]. Ugeskr Laeger. 1994; 156(10):14651467.

23. Harding IJ, Parry D, Barrington RL. The use of a moulded metacarpal brace versus neighbor
strapping for fractures of the little finger metacarpal neck. J Hand Surg Br. 2001; 26(3):261
263. doi:10.1054/jhsb.2000.0509 [CrossRef]

24. Lowdon IM. Fractures of the metacarpal neck of the little finger. Injury. 1986; 17(3):189192.
doi:10.1016/0020-1383(86)90332-3 [CrossRef]

25. Poolman RW, Goslings JC, Lee JB, Statius Muller M, Steller EP, Struijs PA. Conservative
treatment for closed fifth (small finger) metacarpal neck fractures. Cochrane Database Syst
Rev2005; 3:CD003210.

26. Bansal R, Craigen MA. Fifth metacarpal neck fractures: is follow-up required?J Hand Surg
Eur Vol. 2007; 32(1):6973. doi:10.1016/j.jhsb.2006.09.021 [CrossRef]

27. Braakman M. Is anatomic reduction of fractures of the fourth and fifth metacarpals useful?
Acta Orthop Belg. 1997; 63(2):106109.

28. Braakman M. Are lateral x-rays useful in the treatment of fractures of the fourth and fifth
metacarpals. Injury. 1998; 29(1):13. doi:10.1016/S0020-1383(97)00101-0 [CrossRef]

29. Breddam M, Hansen TB. Subcapital fractures of the fourth and fifth metacarpals treated
without splinting and reposition. Scand J Plast Reconstr Surg Hand Surg. 1995; 29(3):269
270. doi:10.3109/02844319509050138 [CrossRef]

30. Geiger KR, Karpman RR. Necrosis of the skin over the metacarpal as a result of functional
bracing: a report of three cases. J Bone Joint Surg Am. 1989; 71(8):11991202.

Authors

The authors are from the Department of Orthopaedic Surgery, William Beaumont Army Medical
Center, Fort Bliss, Texas.

The authors have no relevant financial relationships to disclose.

The views expressed in this manuscript are those of the authors and do not reflect the official
policy of the Department of the Army, Department of Defense, or US government. All authors
are employees of the US government. This work was prepared as part of their official duties, and
as such, there is no copyright to be transferred.

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Correspondence should be addressed to: John C. Dunn, MD, Department of Orthopaedic


Surgery, William Beaumont Army Medical Center, 5005 N Piedras, Fort Bliss, TX 79920 (
dunnjohnc@gmail.com).

Received: August 01, 2015


Accepted: October 13, 2015
Posted Online: March 29, 2016
10.3928/01477447-20160315-05

Previous Article Next Article

Abstract !

Article "

Fractures of the fifth metacarpal neck, or boxer's fractures, are common, particularly among
young men. Because of the high frequency of this injury, there is a considerable range of
treatment options. The purpose of this systematic review was to determine whether reduction
and splint or cast immobilization is necessary for fractures of the fifth metacarpal neck. The
authors conducted a systematic review of all published studies that randomized these
fractures to cast immobilization vs treatment with soft wrap without reduction. Cast
immobilization is not superior to soft wrap without reduction in most cases. The study found
that reduction and cast immobilization is not necessary for boxer's fractures. [Orthopedics.
2016; 39(3):188192.]

The authors are from the Department of Orthopaedic Surgery, William Beaumont Army
Medical Center, Fort Bliss, Texas.

The authors have no relevant financial relationships to disclose.

The views expressed in this manuscript are those of the authors and do not reflect the
official policy of the Department of the Army, Department of Defense, or US government.
All authors are employees of the US government. This work was prepared as part of their
official duties, and as such, there is no copyright to be transferred.

Correspondence should be addressed to: John C. Dunn, MD, Department of Orthopaedic


Surgery, William Beaumont Army Medical Center, 5005 N Piedras, Fort Bliss, TX 79920 (
dunnjohnc@gmail.com).

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Received: August 01, 2015


Accepted: October 13, 2015
Posted Online: March 29, 2016
Fractures of the fifth metacarpal neck, or boxer's fractures, are common, accounting for 20%
of all hand fractures.13 These injuries are most often sustained while striking an object with a
closed fist during impulsive periods,4 during fights,5 or after episodes of alcohol
consumption.69 Although these fractures are typically treated nonoperatively, most often with
closed reduction and splint immobilization,1012 there is concern that residual angulation at the
fifth metacarpal neck may leave patients with discomfort and cosmetic complaints.13,14 The
proposed limit of fracture angulation to minimize functional deficit is 30, without shortening or
rotational deformity.15

However, prospective, randomized studies have shown that regardless of fracture angulation
or treatment method, adequate short-term1620 and long-term21 outcomes are achieved. The
current comprehensive systematic review of all available prospective, randomized studies
compares reduction and splint immobilization vs soft wrap without reduction of boxer's
fractures. This study demonstrates that there is no clear benefit to reduction and splint
immobilization of boxer's fractures.

Materials and Methods


Literature Search
A systematic review of the literature was performed. The following search terms were
queried in PubMed, EMBASE, and Medline for the time period between 1960 and 2015:
metacarpal neck fracture*, boxer's fracture*, and subcapital metacarpal*. Two
independent reviewers (J.C.D., N.K.) assessed the methodology and quality of each study.
Homogeneous data were extracted from studies that met the inclusion and exclusion
criteria, and frequency-weighted means were generated. A PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-Analyses) diagram guided the study selection (
www.prisma-statement.org).

Inclusion and Exclusion Criteria


The inclusion criteria were as follows: (1) prospective, randomized design; (2) treatment of
metacarpal neck fractures; and (3) 2 treatment groups involving splinting vs soft wrap. Soft
wrap techniques in this study included buddy taping or soft wrap. Either self-adherent
wrap21 or silk tape16 was used for soft wrap, and all of these techniques are referred to as
wrap for simplicity.

The exclusion criteria were as follows: (1) non-English-language translation22; (2) any
review, technique article, biomechanical study, or case series without a control group; (3)
any study with unclear methods1; (4) operative management; and (5) any study that
23
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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

included a fracture brace in lieu of a splint (Figure).23

Figure:
Inclusion
and
exclusion
criteria.

If an abstract met the inclusion and exclusion criteria, the authors reviewed the entire text to
verify qualification. In addition, they manually reviewed all references from all studies that
met the inclusion and exclusion criteria to generate a list of qualifying studies not identified
in the electronic searches. The authors met and conferred at this point. There were no
discrepancies between their findings.

Data Extraction and Analysis


Study design, demographic variables (Table 1), outcomes (Table 2), and complications
(Table 3) were extracted and analyzed. Two authors (J.C.D., N.K.) independently extracted
the data, then conferred and compiled the data, correcting any discrepancies. Reported
outcomes varied between studies. To account for the heterogeneity, Table 2 reports which
outcomes specific authors used and which treatment method, either splint or wrap, was
found to be superior.

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Table 1:
Demographics, Study
Size, and Basic
Treatment
Characteristics

Table 2:
Outcomes
of
Fracture
Treatment

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Table 3:
Complications
of Fracture
Treatment

Results
The search resulted in 50 potentially eligible studies; only 5 studies met the inclusion and
exclusion criteria. All studies were prospective, randomized, Level I therapeutic studies
with greater than 80% follow-up (Figure). In total, 215 patients with an average age of 28
years were followed for an average of 13 months. Of these, 106 were randomized to the
splint group and 109 were randomized to the soft wrap group (Table 1). The splint group
did not receive a reduction in 4 of the 5 studies.1619 In these studies, the exclusion criteria
of dorsal angulation, or the maximum angulation without a reduction attempt, was 50 to
70 (average, 59). All splinted patients were placed in the intrinsic plus position.

Outcomes of the 2 cohorts were cumulatively similar across all studies (Table 2).
Braakman et al16 conducted a prospective, randomized study of 48 fifth metacarpal
fractures with 6-month follow-up. Half of the patients were randomized to immobilization
and half were randomized to buddy taping. In all, only 4 patients had a reduction: 2 for
excessive angulation and 2 for a rotational deformity. At 1 week, 4 weeks, and 3 months,
the wrap group had better range of motion (ROM). By 6 months, ROM between the 2
groups was equivalent. Similarly, pulling strength, pronation strength, supination strength,
and torque strength were better for the wrap group at 1 week and 4 weeks. There was a
slight loss in reduction in all 4 patients who had a reduction by 1 week. Initial fracture
angulation did not correlate with outcomes (Table 2).

Statius Muller et al17 followed a series of 35 boxer's fractures for 12 weeks. Fifteen were
randomized to plaster immobilization and 20 were randomized to a pressure dressing and
immediate ROM. At 6 and 12 weeks, there was no difference between the groups in terms

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of metacarpophalangeal joint (MCPJ) ROM, pain, and overall satisfaction (Table 2).

McMahon et al18 treated 42 patients with boxer's fractures, randomizing half to splints and
half to a compression dressing. At weeks 2 and 3, treatment favored the wrap cohort in
terms of ROM and swelling (Table 2).

Hansen and Hansen19 randomized 85 patients with boxer's fractures to treatment with either
a splint, a wrap, or a soft brace. Excluding the brace patients, the wrap cohort had improved
tenderness and MCPJ movement at 4 weeks. However, the splint group had 10 of
additional metacarpophalangeal joint ROM at 3 months. The groups were equally satisfied
at the conclusion of treatment (Table 2).

Kuokkanen et al20 randomized 29 patients with boxer's fractures to closed reduction with
splint vs no reduction and soft wrap with immediate ROM. At 4 weeks, the wrap had
improved metacarpophalangeal joint ROM and grip strength. Although grip strength
remained superior in the wrap cohort at 3 months, ROM was equivalent between the 2
groups. A reduction and splint did not improve the range of angulation from the initial
injury. Furthermore, it is worth noting that this study was randomized; however, the wrap
group had a significantly higher prereduction fracture angulation (Table 2).

In the current study, the complications between the 2 groups were equivalent (Table 3).
Whereas several studies reported no complications, one study reported that approximately
one-third of both the splint and wrap cohorts had some degree of residual symptoms at 3
months.16 Statius Muller et al17 reported that only 1 of 15 patients in the splint group and 1
of 20 patients in the wrap group did not return to work at 6 weeks.

Discussion
The key finding of the current study is that there is no benefit to reduction and splint
immobilization of closed boxer's fractures with initial angulation of less than 70. In fact,
using soft wrap without reduction was generally favored in terms of MCPJ ROM,16,1820
strength,16,20 and swelling.19 Outcomes were generally equivalent in terms of pain17 and
tenderness,19 fracture healing,20 patient satisfaction,17,19 and return to work.17

In the current study, the range of dorsal angulation that was accepted without reduction and
placed in a soft wrap varied from 50 to 70 (Table 1). The degree of dorsal angulation for
a closed boxer's fracture may not correlate with outcome.8,24 An analysis of boxer's
fractures separated into those with dorsal angulation above 30 and those below 30

8
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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

demonstrated no association with functional results.8 A prospective case series of boxer's


fractures with angulation up to 75 treated with buddy taping alone without reduction
exhibited no adverse outcomes.21 Patients in this series had no loss in grip strength, 100%
of fractures healed with no change in fracture angulation, and median Disabilities of the
Arm, Shoulder and Hand (DASH) score was 0 at 3 years. Although the experimental group
in this review was treated with a soft, compressive wrap, buddy taping is an alternative
method for boxer's fracture treatment in place of a splint. It is hypothesized that buddy
taping prevents rotational deformity.16

The current study established that reduction and splint immobilization are not superior to a
soft wrap or buddy tape (Table 2). In a similar systematic review of boxer's fractures,
Poolman et al25 found no superior method of fracture immobilization. Outcomes were at
least equivalent in the short term, and long-term outcomes of wrapping metacarpal fractures
are excellent as well.21 In addition, obtaining long-term outcomes for these injuries is
especially difficult. Hansen and Hansen19 did not attempt a return-to-work analysis in their
cohort because so many of their patients were unemployed, nonworking, or students. In
another prospective analysis of boxer's fractures, Bansal and Craigen26 also had poor
follow-up. The initial 40 patients with a boxer's fracture were treated with reduction and
splint immobilization; however, only half of the patients returned for the follow-up visit.
The second cohort included 38 patients who were treated by buddy taping the fourth and
fifth fingers. In this cohort, only 2 patients returned to clinic. Despite the poor follow-up,
the buddy taping group returned to work over 2 weeks before the immobilization group (2.7
vs 5 weeks). In addition, the 2 groups had equivalent DASH scores at 12 weeks.26

Although the subjective outcomes in the treatment of boxer's fractures are equivalent
between reduction and splint vs soft wrap, the radiographic outcomes were not well
controlled for in the current analysis (Table 2). However, one study noted no difference
between the groups in mean radiographic angulation,18 and another reported no difference
in union rate.20 Furthermore, some authors do not advocate ordering lateral radiographs in
the follow-up period for these fractures.27 Another study of 200 boxer's fractures
demonstrated equivalent residual radiographic dorsal angulation at 4 weeks post-injury in
the treatment group that underwent closed reduction and the group that did not.28

No major complications were identified in the current study (Table 3). There have been
reports of skin necrosis after splinting,29,30 but no cases were found in the current analysis.
Both return to work18 and incidence of residual symptoms (approximately one-third)18 were
equivalent between the 2 cohorts.

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This study has limitations. It included a limited number of patients with inconsistent and
irregular follow-up. Each study used different outcome variables, making it impossible to
combine data. In the future, a well-powered prospective, randomized study with close
follow-up, including specific outcome measures, should be conducted. However, despite
these shortcomings, to the authors' knowledge this is the most complete review of
nonoperative management of boxer's fractures.

Conclusion
Given the reasonable short- and long-term outcomes of wrapping boxer's fractures without
reduction,11,1621,25,28 it is likely that reduction with immobilization of these fractures is
unnecessary. For fifth metacarpal neck fractures with up to 70 apex dorsal angulation and
without a rotational deformity, the best available evidence suggests that a soft wrap with
buddy taping the fourth and fifth digits without reduction yields equivalent results to closed
reduction and splint treatment.

References
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13. Ali A, Hamman J, Mass DP. The biomechanical effects of angulated boxer's fractures. J
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14. McKerrell J, Bowen V, Johnston G, Zondervan J. Boxer's fractures: conservative or


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[CrossRef]

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22. Poulsen MB, Hansen TB, Bang DM. Treatment of subcapital fractures of the 4th and the
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23. Harding IJ, Parry D, Barrington RL. The use of a moulded metacarpal brace versus
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25. Poolman RW, Goslings JC, Lee JB, Statius Muller M, Steller EP, Struijs PA.
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27. Braakman M. Is anatomic reduction of fractures of the fourth and fifth metacarpals
useful?Acta Orthop Belg. 1997; 63(2):106109.

28. Braakman M. Are lateral x-rays useful in the treatment of fractures of the fourth and fifth
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29. Breddam M, Hansen TB. Subcapital fractures of the fourth and fifth metacarpals treated
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30. Geiger KR, Karpman RR. Necrosis of the skin over the metacarpal as a result of
functional bracing: a report of three cases. J Bone Joint Surg Am. 1989; 71(8):1199
1202.

The authors are from the Department of Orthopaedic Surgery, William Beaumont Army
Medical Center, Fort Bliss, Texas.

The authors have no relevant financial relationships to disclose.

The views expressed in this manuscript are those of the authors and do not reflect the
official policy of the Department of the Army, Department of Defense, or US government.
All authors are employees of the US government. This work was prepared as part of their
official duties, and as such, there is no copyright to be transferred.

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The Boxer's Fracture: Splint Immobilization Is Not Necessary | Orthopedics 31/05/2016 14:14

Correspondence should be addressed to: John C. Dunn, MD, Department of Orthopaedic


Surgery, William Beaumont Army Medical Center, 5005 N Piedras, Fort Bliss, TX 79920 (
dunnjohnc@gmail.com).

Received: August 01, 2015


Accepted: October 13, 2015
Posted Online: March 29, 2016

Figures/Tables !

References !

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