Hand iSAWE 7

Question

A 19 year old man presents after a fight with swelling over the ulnar side of his hand.

Hand iSAWE 7, radiograph of the hand
Radiograph of the hand. Image by Louis Philippe Lessard, Wikimedia Commons, CC BY-SA 3.0.
  1. What is the injury and what angulation is acceptable?
  2. When is surgery indicated and what are the options?
  3. What else must be examined?

Answer

Diagnosis

  • Fourth metacarpal neck fracture (boxer’s fracture) with apex dorsal angulation
  • Loss of knuckle prominence on examination

Acceptable neck angulation

DigitAngulation
Index10 to 15 degrees
Middle10 to 15 degrees
Ring30 to 40 degrees
Little50 to 60 degrees

Surgery

  • Rotational malalignment with scissoring
  • Angulation beyond limits or pseudoclawing
  • Open fracture or fight bite
  • Multiple metacarpal fractures
  • Options are closed reduction (Jahss manoeuvre) with an ulnar gutter splint, antegrade intramedullary wires or transverse pinning, and plating
  • Buddy strapping and early motion suit stable fractures within limits

Examination

  • Rotation with the fingers flexed
  • Skin over the knuckle for a fight bite, which needs washout and antibiotics
  • Extensor lag
  • Sensation and capillary refill

Related pages

Author Contributions

Orthofracs team

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.