Hand Case Study 2: Boxers Fracture

James Anderson is a 20 year old apprentice plumber who has been experiencing pain
in his right hand for 2 months since he sustained a fracture to the 5th Metatarsal shaft
following a punch injury. This was fixed internally with a plate and screws. He is
now noticing wasting of the muscles around the thenar and hypothenar eminence and
has decreased grip strength and limited MCP and IP movement of the 3rd and 4th
digits. He is currently off work but needs to grip for prolonged periods but the pain
and lack of grip makes it difficult to return to work. He lives with his parents and
teenage brother in a 3-bed house.

Anatomy & Pathology

Boxer’s fracture – punching something hard – end of metacarpal takes the brunt –
usually breaks at narrower end near the end

The ulnar nerve is shared by 3/4/5/ digits

Hypothenar area ->means around ulna

Thenar area ->means around thumb
Tendons in extension and flexion are shared by digits – see insertion for extensor
digitorum and extensor digitorum

Subjective Examination
Where\What: Fracture at 5th metatarsal, pain & lacks grip - muscle wastage around
3rd and 4th digits – ask where is pain – expect it to be around the fracture point

When: 2 months ago – expect stiffness, muscle wastage from splint

How: punching

0-10 rating: decreasing

24-hour cycle: expect no real change

Better for: rest

Worse for: picking things up

Type of pain: deep pain relates to bone – sharp pain to OA of joint – ask what type of
pain they are experiencing – stiffness and weakness would be an uncomplicated
expectation

Past Medical History/ General History: nil, ask about osteoporosis, bone disease
and previous fractures
Red Flags and general concerns: nerve lesion – pins and needles
Malunion/non-union – joint not healed
Post traumatic arthritis – crepitus

SH: parents and brothers in 3-bed house

DH: nil ask ?

Patient’s main outcome: grip and return to work?

Objective Examination

Working Hypothesis: examine rule out nerve lesion, non/malunion &

arthritis

Advice & Consent: give and obtain

General Observations: watch walking, how use hand if possible – can

offer to gently shake hand.

Acute Observations:
Skin colour – check for remaining bruising
Swelling – check
Positive
Muscle bulk
Deformity – broken bone or knuckle misaligned with affected finger – ask if at break
the finger head had rotated to thumb – can be a permanent bend if knuckle badly
healed => this can affect other tendons.

Active Tests, Passive Tests & Resisted Tests:

- All in sitting with hands and wrists across bed
Inferior Radioulnar – pronation supination
Radiocarpal – flex extension radial deviation ulnar deviation
Carpometacarpal joint of thumb – flexion extension abduction adduction opposition
Metacarpal phalangeal Joint – flexion extension abduction adduction
Proximal & distal interpahlangeal joints – flexion extension
Active – non-union may still see knuckle rotate in finger flexion – malunion may be
evidenced by deviation in tendons on extension – ask if there is any tingling on
flexion of fingers - 3/4th fingers share ulnar nerve with 5th

Passive – stiffness expected = acute pain ( malunion) – sharp pain or crepitus – OA

Resisted – Weakness expected from splint

Special Tests: tinels sign on ulnar nerve – reverse phalens test (hands in prayer
position – hold firmly for 1 minute – extended flexion stretches extensors) will test for
nerve problems – tingling increase in pain => peripheral neuropathy

Functional Tests: picking up small objects = dexterity tests. Strength tests =

squeeze tennis ball – shake hands

Palpation: non-union = rotation of metacarpal head – percussion on bone,

translation of bone indeed severe pain on compression should indicate non-union

Feel for any tendinal problems – is hand skewing on extension - = possible malunion

Listen for OA – listen for creaking – feel for vibrations from rubbing joint surfaces

Measurements: gripometer – record any abnormalities

Advice & Possible Treatment: full healing not apparent – for 2 to 5

months – if everything ok – work on specific exercises for developing grip strength.