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"metacarpal fracture" AND management

Radiographic Findings

Right hand, wrist AP + oblique views (Mr. Ragan, 24 y):
  • A fracture line is visible across the shaft/neck of the 4th (ring) metacarpal, seen on both the AP and oblique projections.
  • The little finger (5th digit) is malaligned - it sits at an abnormal angle relative to the ring finger, with volar (palmar) tilting of the distal fragment and apparent shortening/overlap on the oblique view. This pattern indicates a concomitant fracture of the 5th metacarpal neck/shaft with angulation and likely rotational malalignment.
  • No obvious carpal bone fracture or dislocation; the carpal row and distal radius/ulna appear intact.

Diagnosis

Fracture of the 4th and 5th metacarpal (border metacarpals) of the right hand, with volar angulation of the distal fragment(s) — the classic "boxer's fracture" pattern, most commonly caused by striking a solid object with a clenched fist (direct axial load on the ring/little finger metacarpal necks).
  • Rockwood and Green's Fractures in Adults notes: "The small finger metacarpal neck fracture, termed the 'boxer's fracture,' can often be treated by closed means... in patients with significant angulation of more than [~40°]" surgical fixation may be needed.
  • Miller's Review of Orthopaedics: "MCP neck fracture: boxer's fracture; Jahss maneuver for reduction."
  • Pfenninger and Fowler's Procedures for Primary Care notes angulation up to ~40 degrees is generally acceptable for the 5th metacarpal neck fracture, but rotational deformity must be corrected, and combined 4th/5th metacarpal fractures need closer scrutiny for instability.

What needs clinical correlation

An X-ray alone cannot fully grade severity - the treating clinician should assess:
  1. Degree of angulation (measured on true lateral view) - determines closed vs. operative management.
  2. Rotational deformity - check with fingers flexed for scissoring/overlap of the little finger over the ring finger (a clinical, not radiographic, sign).
  3. Skin integrity - rule out an open "fight bite" wound over the MCP joint, which changes management (risk of septic arthritis).
Typical management: closed reduction and ulnar gutter splint/cast for angulation within acceptable limits and no rotation; percutaneous pinning, intramedullary nailing, or plate fixation for excessive angulation, rotation, or multiple adjacent metacarpal fractures (the combined 4th+5th pattern is often less stable than an isolated 5th metacarpal fracture and more frequently needs fixation).
A recent (2025-2026) systematic review/meta-analysis literature on metacarpal fracture fixation (PMIDs 41525130, 40459447, 38411136) compares intramedullary nailing, plating, and K-wires - all reporting good functional outcomes with device choice depending on fracture pattern and surgeon preference - none contradicts the standard diagnostic approach above.
This is an imaging-based impression only - final diagnosis and treatment plan should be confirmed by the treating orthopedic/hand surgeon after full clinical examination (rotation, neurovascular status, skin) correlated with these films.
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