4th year placement project developed by Madeleine Eaton and Catherine Riddle in conjunction with Monash Health - Hand Therapy Department. Discussed the current best evidence for optimal treatment of 5th Metacarpal neck fractures

1. Hand Therapy - Monash Dandenong
Catherine Riddle and Maddy Eaton
Monash University - 4th Year Student Placement Project

2. What is the optimal
non-operative
management of 5th
metacarpal neck
fractures?

3. Metacarpal Neck Fractures
● 5th MC neck fracture (boxers fracture) are common, accounting for approximately 20% of hand
injuries and 5% of fractures of the upper extremity
● Commonly a result of a closed fist strike and are associated with young working aged males
● Uncomplicated boxers fractures that are typically managed conservatively:
○ Minimally displaced
○ Closed
○ Isolated injuries
○ Fracture angulation of up to 70
degrees
Table 1: Fracture locations among punching-type injuries
(From, Soong, Got and Katarincic 2010)(Pellatt et al, 2019)

4. Occupational Performance and Engagement Impact
Possible Anatomical Complications
○ Loss of knuckle prominence
○ Weakened grip strength
○ Extension Lag
○ Reduced Active Range Of Motion
(AROM) at the Metacarpal
Phalangeal Joint (MCPJ)
Functional Impact
○ Social and economic impact
○ Returning to work
○ Leisure activities - sport
➔ Activity Modification
(Kollitz et al, 2013) (Pellatt et al, 2019)

5. Treatment Options available for uncomplicated
5th MC neck fractures
● A range of options exist for conservative treatment of a 5th MC neck fracture:
○ Immobilisation in cast
○ Buddy taping of ring finger and little finger
○ Functional strapping of the affected hand
○ Splinting
(Pellatt et al, 2019)

6. Current Management
Monash Health Hand Therapy
● Current lod, based on best available evidence and consideration of anatomy
and deforming forces.
● Dorsal hand based splint positioning the affected and neighbouring
metacarpophalangeal joint (MCPJ) in 70 degrees flexion.
● Flexion beneath the dorsal hood is encouraged, with advice to avoid strong
gripping.
● Splint position encourages MCPJ to rest in a degree of flexion, enabling the
base of the proximal phalanx to glide upwards on the volar angulated head
of the metacarpal.
● Clinical union shown to occur between 2-3 weeks following the fracture - no
formal follow-up for these patients.
● Assessment of common complications would guide rationale for follow-up.
(Toeman & Midgley, 2010) (LaStayo, Winters and Hardy, 2003) (Frost, 2001)

7. Literature Review
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8. Level of Evidence Pyramid
Literature Review - Level of Evidence

9. Literature Review - Level of Evidence
Study Design / Methodology Level of
Evidence
Number
located
Authors and year published
High quality systematic review,
meta-analysis
1 2 Poolman et al (2009)
Gulabi et al (2014)
Lower quality systematic review,
randomised control trial
2 5 Dunn et al (2016)
Pekkar et al (2019)
Hansen (1998)
Kuokkanen et al (2009)
Kollitz et al (2014)
Sahu et al (2012)
Controlled trials, Cohort or case
controlled analysis studies
3 2 Kaynak et al (2019)
Aaken et al (2007)
Bansal & Craigen (2007)
Case series 4 0
Expert opinion, descriptive studies,
single case studies, consensus
statements
5 4
Eldrudge & Apau (2015)
Abdelmalek Harrison & Scott (2015)

10. ResultsFifth metacarpal neck fracture: Is follow-up
required?
Bansal, R. & Craigen, M. (2007). Fifth metacarpal neck fracture: Is
follow-up required?. Journal of Hand Surgery, 32(1), 69-73. Doi:
10.1016/j.jhsb.2006.09.021

11. The boxer’s fracture: splint immobilisation
is not necessary.
Dunn, J. C., Kusnezov, N., Orr, J. D., Pallis, M., & Mitchell, J. S. (2016). The boxer's
fracture: splint immobilization is not necessary. Orthopedics, 39(3), 188-192. Doi:
https://doi.org/10.3928/01477447-20160315-05

12. 68 patients, 58 patients with MC fractures, majority neck
fractures.
Closed fifth meacarpak neck fractures: Do they
need to be seen in fracture clinic?
Abdelmalek, A., Harrison, E., & Scott, S. (2015). Closed fifth metacarpal neck
fractures: Do they need to be seen in fracture clinic? An emergency department
pathway for assessment, management and criteria for fracture clinic referral.
Trauma, 17(1), 47-51. Doi: 10.1177/1460408614545253

13. Follow Up
Table 1: Follow-up following conservative treatment
(Sahu et al, 2011)
The Current Practice of the management of little finger
metacarpal fractures - A review of the literature and results of a
survey conducted among upper limb surgeons in the UK

14. Psycho-social factors to consider

15. Considerations for treatment intervention
of Metacarpal fracture 1-4
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(Kollitz et al, 2013)

16. Recommendations

17. Recommendations
1. Initial Hand Therapy Appointment through clinic
2. Meet criteria for simple 5th MC neck fracture
3. Treat with buddy tape of Little finger and ring finger and provide soft wrap from base of wrist to MCPJ level
4. Provide patients with information leaflet about
I. Basic information about injury
II. Pain and swelling
III. Expected functional outcomes and cosmetic appearance
IV. Mobilisation
V. Return to work
VI. Return to contact sports
VII. Reasons for concerns
VIII. Hygiene and application of buddy tape
5. Patient to self-initiative follow up appointment if any of the outlined concerns arise

18. Soft Wrap
Self - Adherent Wrap - Coban: covering metacarpal bones 2-5
(Aaken et al, 2007)

19. Treatment Pathways

20. References

21. References

22. References
Meena, S., Sharma, P., Sambharia, A. K., & Dawar, A. (2014). Fractures of distal radius: an overview. Journal of family medicine and
primary care, 3(4), 325.