Hand Case 1 ED Management
5th metacarpal neck fracture (Boxer's fracture)
Emergency department management includes reduction and placement of an ulnar gutter splint. Prior to reduction, a hematoma or ulnar nerve block may be performed. In the former, a needle is inserted into the fracture and blood aspirated to confirm appropriate placement, then 5cc of lidocaine (without epinephrine) or bupivacaine is injected. For an ulnar nerve block, 5cc of anesthetic is injected proximal to the ulnar styloid between the ulnar artery (medial) and the tendon of the flexor carpi ulnaris (lateral).
To achieve reduction, the hand is held in a clenched fist, while simultaneous dorsal force is applied on the flexed PIP joint and volar force applied to the proximal metacarpal shaft.
An ulnar gutter splint should be applied with the hand held in the "safe" position (20 degrees of wrist extension, MCP joints flexed to 90 degrees and the PIP and DIP joints extended) to tighten collateral ligaments and maintain reduction.
Follow-up with a hand surgeon should be arranged in 7-10 days. If closed reduction cannot be maintained, or if significant rotation or angulation persists, surgical fixation may be required to prevent functional deficit.