Daily Radiology Case

Explanation

A boxer fracture is a fracture of the neck of the 5th metacarpal, most commonly caused by a closed-fist strike against a hard surface such as a wall or another person. It is one of the most common hand fractures and typically presents with pain, swelling, and deformity over the ulnar side of the hand near the small finger knuckle. Patients may report decreased grip strength and pain with hand movement. On physical exam, there may be tenderness over the 5th metacarpal, swelling, loss of the normal prominence of the 5th knuckle, and sometimes rotational deformity of the small finger. Demographics: Common in adolescents and young adults, especially after punching injuries. Etiology: Axial loading force through a clenched fist causes fracture of the metacarpal neck, most often the 5th metacarpal. Course: Most uncomplicated fractures are managed nonoperatively with immobilization, though significantly angulated or rotationally deformed fractures may require reduction or surgical fixation. Radiology: Hand X-ray demonstrates a fracture through the neck of the 5th metacarpal, often with volar angulation of the distal fragment. Treatment: Initial treatment is typically ulnar gutter splinting, pain control, and orthopedic follow-up. Closed reduction may be needed if angulation is significant. Surgery may be indicated for open fractures, malrotation, intra-articular extension, or severe deformity. Differentials: 5th metacarpal shaft fracture: fracture is more proximal rather than at the neck 4th or 5th carpometacarpal dislocation: can also occur after punching injury and may be subtle on X-ray Fight bite injury: laceration over the MCP joint after punching another person; important because of infection risk and need for antibiotics

Source: Lustosa L, Boxer fracture. Case study, Radiopaedia.org (Accessed on 19 Mar 2026) https://doi.org/10.53347/rID-148077

Hints

• Teenage male presents with hand pain after punching a wall in anger
• Pain and swelling are localized to the ulnar side of the hand near the small finger
• Physical exam shows tenderness over the 5th metacarpal with decreased prominence of the pinky knuckle
• Patient is able to move the fingers but has pain with making a fist
• Hand X-ray shows a fracture of the 5th metacarpal neck with angulation