Intended for healthcare professionals

Endgames Case Review

A patient with a painful and swollen hand

BMJ 2017; 358 doi: (Published 20 July 2017) Cite this as: BMJ 2017;358:j3127
  1. Alexander EJ Trevatt, core surgical trainee, year 2,
  2. William Maynard, foundation year 2,
  3. Roger Adlard, consultant plastic and reconstructive surgeon
  1. Plastic and reconstructive surgery department, St George’s University Hospitals NHS Foundation Trust, London, UK
  1. Correspondence to A Trevatt alextrevatt{at}

A 26 year old man presented to the emergency department with a painful and swollen right hand. The previous night he had punched a wall. He was previously fit and well with no substantial medical history.

On examination his hand was swollen and bruised, but there was no open wound. He had tenderness over the dorsum of the hand, particularly over the fifth metacarpal. There was no obvious deformity, scissoring, or malrotation of the fingers, but he was unable to make a full fist due to the pain. On extension there was an extensor lag of the little finger.

Radiographs were taken (fig 1) and his hand was put in a volar backslab.

Fig 1

Radiographs of the patient’s right hand: anterior-posterior (left), oblique (middle), and lateral (right)


  • 1. What injury has the patient sustained?

  • 2. How should a patient with this diagnosis be managed?

  • 3. What are the potential complications of this injury?


1. What injury has the patient sustained?

Short answer

The patient has sustained a closed fracture to the neck of the fifth metacarpal of his right hand, also known colloquially as a “boxer’s fracture.” The radiographs show a simple extra-articular fracture with approximately 50° of volar angulation.


Fractures of the fifth metacarpal are common injuries, accounting for 10% of all hand fractures.1 The five metacarpals make up the body of each hand, articulating proximally with the trapezium, trapezoid, capitates, and hamate, respectively, and distally with the proximal phalanges. The fifth metacarpal articulates proximally with the hamate, laterally with the fourth metacarpal, and distally with the fifth proximal phalanx.

Fractures of the fifth metacarpal most commonly occur after …

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