WIDI - M7) Hand pain after punching a refrigerator

M7) Hand pain after punching a refrigerator

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hand pain.
Review the DDx considerations in hand pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with hand pain.

History

A 27-year-old man presents to the emergency department due to severe right-hand pain after getting into argument and punching his refrigerator with a closed fist. He rates the pain an 8/10 in severity and describes it as sharp and throbbing.

Physical Exam

BP: 128/82, HR: 88, RR: 19, Temp: 37 C, O2 saturation 100%. MSK: There is focal tenderness to palpation over the mid-portion of the 5th metacarpal bone. Apex volar angulation is seen resulting in depression of the MCP joint and loss of normal knuckle contour. Limited ROM in pinky finger secondary to pain. Neurological: Right hand sensation and motor function intact. Skin: Ecchymosis at the dorsum of the 5th metacarpal. There is swelling of the dorsum of the ulnar aspect of the hand.

Labs

None.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Hand Contusion

Boxer’s Fracture

Metacarpopharyngeal joint dislocation

Rolando Fracture

The patient likely has a boxer’s Fracture considering the presentation (localized pain on the dorsum of the 5th metacarpal following trauma to his clenched fist) and physical exam (5th metacarpal neck is tender, ecchymosis, and angulation is seen leading to loss of normal knuckle contour)

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

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While this patient’s condition is not immediately life or limb threatening, they require expedited workup.

First Imaging Study

What is the first imaging study you will order?

Ultrasound

Radiography

MRI

CT Hand and Wrist

Radiography of the hand is an inexpensive initial imaging modality that is often sufficient to diagnose and characterize fractures.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Hand X-Ray

What best describes the findings on the hand radiographs?

The 1st MCP joint has an oblique fracture

The 5th MCP joint has an oblique fracture

The 5th carpo-metacarpal joint is dislocated

Swelling is observed between the first and second metacarpals

There is an oblique fracture through the distal fifth metacarpal at the neck.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

MRI

CT Hand and Wrist

None

No further imaging is needed since the diagnosis is confirmed with clinical examination and radiography.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Hand Contusion

Rolando Fracture

Metacarpopharyngeal joint dislocation

Boxer's Fracture

The patient has a boxer’s fracture secondary to a traumatic incident (punching the refrigerator with a closed fist). Imaging confirms the provisional diagnosis.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

While this patient’s condition is not immediately life or limb threatening, they require expedited workup.

Assessment and Plan

Please provide your assessment and plan for this patient

The patient is a 35-year-old man presenting with hand pain after punching a refrigerator with a closed fist. Radiography confirmed the suspected diagnosis of a boxer’s fracture. Considering that the fracture is closed, non-comminuted, and without significant angulation, the patient may undergo conservative management with fracture immobilization using an ulnar gutter splint. The patient should also be provided with information for a home program to regain their range of motion.

Lessons Learned:
- A boxer’s fracture is a 5th metacarpal neck fracture that is more commonly seen in men and accounts for approximately 10% of all hand fractures.
- It presents clinically with pain on the dorsum of the 5th metacarpal along with ecchymosis, swelling, and potential angulation of the fracture apex.
- Radiography is the initial imaging test sufficient to establish the diagnosis and determine degree of displacement.
- Splinting is the standard of care for patients with this diagnosis. Surgical intervention is typically indicated during cases of open metacarpal neck fractures, fractures resulting in neurovascular abnormalities, comminuted fractures, or angulated fractures.

Socioeconomic Factors:
- Boxer’s fractures most commonly occur in Caucasian males aged 19 to 38 with a lower socioeconomic status.
- Most cases of boxer’s fracture are caused by alcohol, which also contributes to putting off prompt treatment.

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Contributors:
Jay Talati, MS2 - Content Contributor
Eva Merlob - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator