A 22-year-old male presents to the emergency department with pain and swelling over the dorsum of his right hand after punching a wall in anger. Clinical examination reveals a closed fist deformity with the 5th finger appearing to deviate slightly toward the midline. A lateral X-ray of the hand is obtained. The structures marked **D** in the diagram show normal alignment. However, the distal neck of the 5th metacarpal is fractured with 35° of volar angulation. Which of the following is the most appropriate management?

## Why Option 1 is correct The clinical anchor states that boxer fractures (distal 5th metacarpal neck fractures) with angulation between 30–40° require reduction and casting in the James position (MCP flexed 70–90°, IP extended) to maintain reduction and allow early mobilization of the interphalangeal joints. The 35° angulation in this case exceeds the threshold for conservative management alone (which accepts up to 30–40° without intervention if there is no rotational deformity), and the patient's clinical presentation (5th finger deviation toward midline on fist) suggests possible rotational deformity, mandating immobilization. The lateral X-ray view is critical for assessing angulation accurately, as AP views can be masked by overlap with adjacent metacarpals. The James position prevents loss of reduction while allowing IP joint motion to prevent stiffness—the standard of care per Apley 10e. ## Why each distractor is wrong - **Option 2 (Immediate ORIF)**: ORIF is reserved for unacceptable angulation (>40° in 5th MC), rotational deformity, open fractures, or multiple fractures. At 35° with no confirmed rotational deformity on examination, closed reduction and casting is the first-line approach. ORIF is overtreatment at this stage. - **Option 3 (Observation alone)**: While 35° angulation is near the upper limit of functional tolerance, the clinical sign of 5th finger deviation suggests possible rotational deformity, which is never acceptable and always requires immobilization. Additionally, the anchor explicitly states that angulation >30° in the 4th MC and >40° in the 5th MC requires intervention. - **Option 4 (Intrinsic-plus position)**: The intrinsic-plus position (MCP extended, IP flexed) is used for other hand injuries (e.g., dorsal hand lacerations, some PIP injuries) but is contraindicated in boxer fractures. The James position (MCP flexed 70–90°, IP extended) is the standard for metacarpal neck fractures to maintain reduction and prevent stiffness of the IP joints. **High-Yield:** Boxer fracture management hinges on three factors: angulation threshold (30–40° for 5th MC), rotational deformity (never acceptable—assess by fist test), and immobilization in James position (MCP 70–90° flexion, IP extension) to maintain reduction while preserving IP mobility. [cite: Apley 10e — Metacarpal Fractures and Boxer Fracture Management]