INTRODUCTION

Background

Punching a wall is an under-recognized yet significant form of nonsuicidal self-harm. Research indicates that individuals who engage in this behavior to alleviate negative emotions often simultaneously harbor a need for assistance and suicidal ideation [1].

Hand and wrist injuries are among the most frequent traumatic presentations in emergency departments (EDs), representing approximately 30% of all injuries. Fractures predominate, with metacarpal and phalanx fractures being most common [2]. Economically active men under 40 years, primarily from the working class, are most frequently affected. Although these injuries may seem minor, they can significantly impair hand function and lead to considerable short- and long-term morbidity [3,4].

Fist injuries, a subset of self-harm behaviors, involve deliberately striking an object with a clenched fist [5]. Research has shown that patients with recurrent hand injuries and metacarpal fractures resulting from punching exhibit elevated levels of anxiety and impulsivity. Accordingly, psychiatric evaluations are recommended to prevent future injuries [6].

Objectives

Our study aimed to identify the demographic and clinical features of patients presenting to the ED with intentional punch injuries and to explore the psychosocial factors associated with these injuries.

METHODS

Ethics statement

This study was approved by the Institutional Ethics Board of Kayseri City Hospital (No. 1016). The requirement for informed consent was waived due to the retrospective nature of the study.

Study population

This retrospective study was conducted at Kayseri City Hospital (Kayseri, Turkiye), a tertiary and regional facility that admits an average of 100,000 trauma patients annually. We included patients aged 16 years and older who presented to the ED with injuries resulting from intentional punches between January 1, 2023, and December 31, 2023. Only patients with closed fist injuries were included. Patients whose fist injuries were not due to punching a wall or object (e.g., injuries sustained from falling on a clenched fist) were excluded.

Sample size

Our records indicate that 13,180 adult patients were admitted to the ED trauma division between January 1 and January 31, 2023. Among these patients, 175 experienced both intentional and unintentional punch injuries. Using the Stat Calc program (Epi Info ver. 7.2.6, US Centers for Disease Control and Prevention) with parameters of a 99% confidence level, a 5% margin of error, and an estimated prevalence of hand injuries at 10% among trauma patients, the calculated sample size was 239. Accounting for a 10% missing data rate, the minimum required sample size was set at 263.

Statistical analysis

Categorical data were expressed as frequencies and percentages, whereas continuous variables were presented as mean±standard deviation or median (interquartile range), depending on their distribution. The Shapiro-Wilk test was used to assess the normality of continuous measurements.

RESULTS

In 2023, 540 patients presented to our ED due to wall-punching incidents. We excluded 63 patients for whom data were inaccessible and an additional 72 patients who did not undergo direct x-ray imaging. Therefore, a total of 405 patients were included in the study.

The median age was 30 years (interquartile range, 22–40 years; minimum to maximum range, 16–76 years), and 363 (89.6%) were male. Moreover, 361 (89.1%) were under 50 years of age. Upon admission, 221 (54.6%) reported punching a wall or another hard object. Other patients initially attributed their injuries to falls, hands becoming trapped between objects, or sports-related activities, but later admitted to punching a hard object. Notably, 313 patients (77.3%) used their right hand when punching.

A total of 389 fractures were identified in 362 patients (89.4%). These fractures were predominantly located in the fourth and fifth metacarpal bones, affecting both the base and shaft. Overall, metacarpal fractures comprised 372 out of 389 fractures (95.6%), while phalangeal and carpal fractures accounted for 13 (3.3%) and 4 (1.0%), respectively. The fifth metacarpal was the most frequently injured (67.4%), followed by the fourth (10.0%) and third (7.7%) metacarpals.

The first metacarpal base was the most common fracture site (77.8%), while shaft fractures were prevalent in the second, third, fourth, and fifth metacarpals. A total of 259 patients (71.5%) presented with nondisplaced fractures. In the ED, most patients were treated with volar splints (73.8%) or volar sandwich splints (20.4%) (Table 1).

Orthopedic specialists performed surgical interventions on 18 patients (5.0%), and 6 (1.5%) required suturing for skin lacerations. Additionally, 31 patients (7.7%) had prior ED admissions for punching-related injuries, while 17 (4.2%) had previously visited the ED for trauma resulting in a fracture. Moreover, 63 patients (15.6%) reported a history of psychiatric drug use (Table 1).

When assessing individual metacarpal fractures, a total of 372 were identified, with 11 cases involving multiple locations. Boxer’s fractures (fifth metacarpal neck fractures) constituted 33.2% of all fifth metacarpal fractures and 22.7% of all metacarpal fractures (Table 2, Figs. 1, 2).

DISCUSSION

This study aimed to determine the frequency, severity, and anatomical location of injuries in patients presenting to the ED of a tertiary hospital with intentional punch injuries. Hand injuries constitute a significant portion of ED visits and carry important implications for healthcare resource utilization, patient morbidity, and socioeconomic factors. Such injuries typically result from impacts, falls, crush injuries, or other major traumatic events. Intentional punch injuries represent a critical subset of hand injuries, largely due to their preventability [4].

A recent study found that hand fractures accounted for 7.6% of all trauma-related emergencies involving bone fractures, with fifth metacarpal fractures being the most common at 39.7%. The study also showed that young men were most frequently affected, with a male to female ratio of 5.5 among those under 50 years old [7]. Similarly, our study found that young men were predominantly affected, with a male to female ratio of 8.6 and 89.1%of patients under 50 years. Notably, the male to female ratio in intentional punch injuries was significantly higher compared to all hand injuries [4,8].

An epidemiological study of approximately 2,300 patients found that right-hand injuries most commonly result from falls, crushes, punches, hyperextension, and compression injuries, while left-hand injuries are often due to chainsaws, automotive accidents, and chain-related incidents [3]. In our study, most patients sustained right-hand injuries, likely because the right hand is typically the dominant hand in the population.

Metacarpal fractures are the third most common type of upper extremity fractures and the second most common hand fracture, accounting for roughly 40% of all hand injuries. The incidence of fractures increases from the radial to the ulnar side, with the fifth metacarpal being the most frequently fractured. Additionally, metacarpal fractures may occur in isolation or alongside other bone injuries [9–11]. Consistent with these findings, our study identified the fifth metacarpal as the most commonly fractured bone from punching, followed by the fourth and third metacarpals.

First metacarpal fractures require particular attention due to the limited support structures. Thumb metacarpal fractures often occur at the base and are usually caused by axial loading forces. Notably, intra-articular first metacarpal fractures, such as Bennett and Rolando fractures, are clinically significant [12]. In our study, 4.6% of patients with closed fist injuries had first metacarpal fractures, most of which were base fractures.

Fractures of the head and base of the second, third, fourth, and fifth metacarpal bones (excluding the thumb) are uncommon and are usually associated with significant joint disruption. In contrast, shaft fractures in these bones are more common, typically resulting from closed fist injuries or high-energy impacts [13]. Similar to these findings, our study observed that base and head fractures of the non-thumb metacarpals were less frequent than shaft fractures.

The fifth metacarpal, along with the radial wrist and thenar region, is particularly susceptible to trauma, making it an anatomical danger zone [2]. Fifth metacarpal neck fractures, also known as boxer’s fractures, typically result from direct axial trauma to a closed fist [14]. Our study corroborates this, as injuries to the fifth metacarpal were most common, with boxer’s fractures constituting 33.2% of fifth metacarpal fractures and 22.7% of all metacarpal fractures.

Most metacarpal fractures can be effectively managed with nonsurgical techniques, particularly when they are minimally displaced or stable. Fifth metacarpal fractures often respond well to conservative treatment. However, certain conditions—including intra-articular fractures, multiple traumas, severe soft tissue injuries, open fractures, fractures with bone loss, and others—require prompt surgical intervention. Fractures that are irreducible or re-displace after reduction are indications for subacute surgery [11,15]. In our study, 71.5% of fractures were nondisplaced, and only 5.0% of patients required surgical treatment.

Our study found that approximately half of the patients did not initially disclose the true nature of their incident upon ED admission. They often cited explanations such as falling, having their hands caught between objects, or sustaining sports-related injuries, but later admitted to punching a hard object. Previous research suggests that such dishonesty in the doctor-patient relationship may arise from a desire to avoid potential punishment, preserve dignity, maintain self-esteem, and resolve role conflicts [16]. In our study, patients likely concealed the true cause of their injuries due to concerns about legal consequences and personal embarrassment related to their loss of anger control.

A study on boxer’s fractures found that approximately one-third of patients experienced recurrent injuries, suggesting that boxer’s fractures resulting from punching may signal a risk of intentional, repeat injuries [17]. In our study, 7.7% of patients had prior ED visits for punching-related injuries, and 4.2% had previously presented to the ED for trauma resulting in a fracture. These findings imply that patients with intentional punch injuries may be at risk for recurrent ED visits.

Limitations

This study has several limitations. First, it was a single-center retrospective study. Second, in the city where the research was conducted, two major hospitals also treat minor trauma patients, which may mean that the actual number of recurrent ED visits is higher than reported. Additionally, excluding patients with punch injuries who did not undergo radiography further limits the study.

Conclusions

In our study, most patients presenting with fist injuries were young men, with a male to female ratio of 8.6. The fifth metacarpal was the most commonly fractured bone, followed by the fourth and third metacarpals. Boxer’s fractures accounted for 33.2% of fifth metacarpal fractures, and shaft fractures predominated in all metacarpals except for the thumb. Approximately three-fourths of patients had nondisplaced fractures, with only 5.0% requiring surgical intervention. Moreover, 7.7% of patients had a history of prior ED visits for punching-related injuries, and 4.2% had previously presented to the ED for trauma resulting in fractures.

ARTICLE INFORMATION

Author contributions

Conceptualization: İ Toker, ÖS, TŞ; Data curation: ME, İ Tüysüz, BK, MİÖ; Formal analysis: İ Toker, MA, İG; Investigation: İ Toker, MA, İG; Methodology: İ Toker, ÖS; Supervision: MA, ÖS, TŞ; Writing–original draft: İ Toker, MA, İG; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Rates of metacarpal bone fractures in study patients.

Fig. 2.

X-rays of the fractures. (A) A base fracture of the first metacarpal. (B) Second metacarpal shaft fracture. (C) Oblique third metacarpal shaft fracture. (D) Fracture of the fourth metacarpal shaft and fifth metacarpal neck. (E) Fourth metacarpal shaft fracture. (F) Fifth metacarpal head fracture. (G) Fifth metacarpal neck fracture. (H) Fifth metacarpal shaft fracture. (I) Fifth metacarpal base fracture.

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Figure & Data

References

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