A 35-Year-Old Man with Pain After Punching a Wall

 Differential Diagnosis

• Boxer’s fracture
• Ulnar styloid fracture
• Distal radius fracture
• Fracture/dislocation base of the 5^th metacarpal
• Osteochondritis dissecans

Diagnosis

There is poor visualization of the 5th metacarpal hamate articulation on the PA view and malalignment of the joint space on the lateral and oblique images. The lateral view also shows a small bone fragment adjacent to the base of the 5th metacarpal. The 5th digit shows ulnar deviation. This patient sustained a 5^th metacarpal-carpal fracture dislocation.

Learnings/What to Look For

• The most common mechanism of injury for this diagnosis is trauma from punching.
• The 5th metacarpal-carpal joint is most commonly involved.
• Ulnar deviation of the 5th digit can be a clinical clue, since severe swelling of the midhand and wrist can limit physical exam.
• May be associated with a hook of hamate fracture.

Pearls for Initial Management and Considerations for Transfer

• With evidence of an isolated fracture, splinting with an ulnar gutter splint or volar splint is appropriate. With a fracture and dislocation, transfer is required for reduction.
• The neurovascular status should be established upon initial assessment, and if not intact then emergent reduction or transfer should be performed.
• Other indications for transfer include intractable pain, consideration of vascular injury, compartment syndrome, or open fracture.

Acknowledgment: Image courtesy of Teleradiology Specialists.