Case Study: Fractured Hand

Case Study Fractured HandIntroduction The reflective framework chosen for this cutting study is that of Peters (1991). This framework has been utilize and favourable evaluated inside education ( chime and Gillett, 1996). Peters (1991) reflective framework incorporates a guideline telephoneed DATA comprising four stepsDescribeAnalyseTheorizeActionThe origin step is the description of an aspect of practice the clinician wants to change. Identification would be make of the context and the priming coat the clinician wants to change the practice and their feelings closely this. Analysis involves identification of the factors that soften to and the assumptions that support the present approach. This includes analysis of beliefs, rules and motives supporting the present approach (Imel, 1992). Theorizing is the next step which looks at the theories for developing a new approach building on the theories that were identified that were supporting the present approach. The final step is t he action putting the new theories (if appropriate) into practice to ensure that such(prenominal) cases continue to be managed appropriately in the future. Success of this process would occur only through additional thought and reflection (Murray, 2006).DATA DescriptionPatient presentationAt 11 am a 64 year old lady presented to the Accident and Emergency Department with a painful right wrist following a fall. We shall call her Betty but, in order to protect convinced(p)iality, that was non her real name. She had been brought to the department by car by her husband.Patient assessmentHistoryBetty was seen by the triage nurse and posterior upon waiting her turn was allocated a cubicle. I saw her at 11.20 hours.An understanding of the pathophysiology of chap is important if important aspects of the patients history are not to be missed. Firstly taking an adequate history of the accident, including details of the mechanism of the fall, depart help the clinician to decide whether th e amount of force applied to the beat would be of the degree that would be expected to ca put on that particular wear out. Secondly there may be underling osteoporosis leading to go bad with minimal trauma. There may be factors in the history suggestive of osteoporosis e.g. use of systemic steroids (Angeli, 2006) or early menopause without subsequent hormone replacement therapy. A fall apart which occurs aft(prenominal) only minimal trauma and from a standing height or less, the degree of trauma being that which would not linguistic rulely be expected to fracture healthy bone, may be what is cognize as a fragility fracture. This occurs where a bone is weakened by a pathological process , (Majid and Kingsnorth, 1998) such as osteoporosis. In distinction a pathological fracture occurs because of metastatic bone disease. Thirdly not just the mechanism of the fall but the reason for the fall needs to be considered. Betty had slipped on some ice when walking outside to her car. I n the absence of such a clear history otherwise factors in the history should be considered for instance funny turns, visual problems, cerebrovascular accidents, or non accidental injury. It is important to directly enquire about that last aspect. examinationOn inspection Bettys right wrist was swollen. The skin was intact. There was some distortion of the normal contour of the arm typical of a dinner party folk deformity. The distal part of the radius was angulated dorsally, the wrist supinated and the hand deviated towards the thumb. On palpation the distal radius was markedly tender. There was no crepitus. Betty was unable to use her right arm at all. The radial and ulnar pulses were readily palpable and there was good capillary refill in the hand. Sensation in the radial, ulnar and median nerve dermatomes was normal as were finger and thumb vogues. The preliminary diagnosis of Colles fracture was made with some degree of confidence since the patient was a 64 year old female w ho had fallen on an outstretched and had classic examination findings of such a common injury.InvestigationsFor a completely confident diagnosis a plain X ray was required. For an X ray of a suspected fractured limb the following are requirements (Majid and Kingsnorth, 1998)The X ray should be in two different planes at right angles.The X ray should involve the joint above and below the suspected fracture site. In this case the wrist and the cubitus.DiagnosisX ray examination of Bettys arm revealed a transverse extra articular fracture of the distal radius within one inch of the wrist joint. The distal radial fragment was displaced dorsally. A Colles fracture could now be diagnosed with confidence.ManagementAnalgesia was given by intra muscular injections of morphine 10 mg and stemetil 12.5 mg. The arm had been temporarily immobilised with a splint and elevated to prevent further injury and swelling prior to the X ray examination. Arrangements were made for prompt reduction of the fracture. The displaced fracture was swerved and manipulated and accordingly immobilised. Betty chose to have a general anaesthetic for this procedure.To disimpact the fracture Bettys hand was pulled distally whilst her wrist was hyper extended. at a time dis encroachment had been achieved the wrist was manipulated so that it was flexed with some ulnar deviation and pronation. In this position it was immobilised by a affix over cast which extended from just distal to the elbow to the metacarpophalangeal joints. These joints (and therefore the plaster) were at the site of the transverse skin crease across the palm. When the plaster had been applied Betty could move her elbow joint and her fingers and thumb. A check X ray confirmed the bone ends to be in a satisfactory position.Post operative instruction Betty was advised to wear her right arm in a sling and to move her shoulder, elbow and her fingers and thumb to prevent stiffness in these joints. Complications of immobilisatio n in fracture are joint stiffness and tissueand particularly muscle, atrophy. An important and serious complication is Sudeks atrophy which probably occurs due to neurological and microvascular compromise. Better was instructed to contact the hospital if her fingers became painful, swollen, cold or discoloured. This could indicate that the plaster was too tight and impeding the circulation. Rarely carpal tunnel syndrome can occur due to pressure on the median nerve at the wrist. Betty was then discharged once she had recovered fully from the anaesthetic and was able to walk around. Betty asked if she could drive and this was allowed following evidence that driving is safe with a right Colles plaster (Blair, 2002). A further review was preend for one week. Betty was advised that the fracture would most likely heal in four to six weeks. Once the fracture had healed by six weeks the plaster was removed and physiotherapy was advised.DATA AnalysisOn analysis of the case presentation it is apparent that the well known clinical features of a fracture were presentPainTendernessSwellingImmobilityDeformityas were the five classical features of a Colles fracture, often called the dinner fork deformity (GP Notebook, 2006)Dorsal displacement of distal fragmentDistal fragment dorsally angulatedHand deviated towards the thumbWrist joint supinatedProximal impactionThe absence of crepitus force be explained by the fact of the fracture being impacted.A fracture of the distal radius is one of the commonest fractures in adults (Majid and Kingsnorth, 1998). The Colles fracture was first gear described by Collees in 1814 (GP Notebook 2006) and is a transverse fracture across the distal radius within one inch of the wrist joint with dorsal displacement and angulation of the distal part of the radius.Sometimes a Colles fracture is associated with a fracture of the ulnar styloid (GP Notebook, 2006) and this must be sought on X ray. A Galeazzi fracture (GP Notebook, 2006) is a dist al radial fracture associated with a dislocation of the distal radio-ulnar joint and is important to diagnose (also by means of an X ray) since it requires open fixation to promote adequate better. Another injury also caused by a fall on the outstretched hand and which it is important not to miss is a fractured scaphoid (Hodgkinson, 1994). This is clinically characterised by tenderness in the anatomical snuff box which is that area on the back of the hand put together by hyperextension of the thumb. If present this fracture mandates appropriate immobilisation to reduce the risk of subsequent disabling avascular necrosis. Other injuries can occur following a fall on the outstretched hand, such as fractures to the clavicle, humerus and other parts of the radius hence the need for the wide area of view on X ray examination.Although the presentation was a typical one there was not a mechanism in place to arrange suitable follow up for Betty to see if measures were necessary to protect her from subsequent osteporotic hip fracture. This problem is not an uncommon one in accident and pinch departments as found by a systematic review of 35 studies showing that those individuals with fragility fractures seldom received investigation or treatment of osteoporosis (Giangregorio, 2006). The writer feels that such action would be important since Colless fracture is common and hip fracture a devasting condition. The writer feels that quite simple steps could be put in place to arrange appropriate follow up.An analysis of why Colles fractures are commoner in women than in men needs to consider the full picture. For instance initially it might be assumed that because postmenopausal women are lacking in oestrogen and therefore predisposed to osteoporosis that is the only reason. However research has shown that women have more falls than men and they are more likely, when they fall, to fall forwards onto the outstretched hand (ONeill, 1994).There is an assumption that the ri sk assessment for likelihood of subsequent hip fracture will be dealt by someone else. The accident and emergency department does need to concentrate on the acute problem. However hip fracture will necessitate subsequent accident and emergency department involvement. Preventative measures may be a neglected but important aspect of the accident and emergency role despite resources being an ever restraining factor.DATA TheorizingFracture healing is affected by general and local factors (Majid and Kingsnorth, 1998). The general factors include the patients age, wellbeing, nutritional and endocrinological state. With regard to the local factors a compound fracture (i.e. a fracture which involves breach of the overlying skin) incorporates a risk of infection which will mischief healing. Local factors affecting healing include the site of the fracture, proximity of bone ends and adequacy of blood supply. The pathophysiology of fracture healing consists of three stages (Majid and Kingsnor th, 1998)Inflammatory phase muddle phaseRemodelling phaseIn the inflammatory phase haematoma contains osteoclasts which remove dead bone. Over two weeks granulation tissue forms which contains osteoblasts which form new bone. In the reparative phase the granulation tissue becomes fibrocartilagenous callus. The callus gradually turns into bone during the consolidation phase. Remodelling occurs as the bone adapts under the influence of the stresses placed upon it.Delayed union occurs when healing requires an excessive duration and non union when there is a failure to heal. Factors associated with poor union include a poor blood supply or displaced bone ends. Treatment is aimed at reducing this risk by optimising the position of the fragments and immobilising them.To develop a new approach to the prophylaxis of hip fracture will require multidisciplinary harmony with the formulation of guideline for nurture giving to both patient and general practitioner. Ideally an appointment would be generated for the bone mineral density scanning and describe and advising. A mechanism of patient information will be required in parallel.DATA Actions proposedTreatment planThe aims of the proposed action were to achieveHealing of the bone, andpreservation of function of the arm and wrist joint.There was more than minimal displacement of the fractured bone therefore manipulation was required. During manipulation it was important to pull the hand in order to disimpact the fracture. Manipulation then involved a reversal of the position that was present making up the dinner fork deformity.ManagementIf the fracture is displaced this may, if leave untreated, lead to breach of the overlying skin and convert a closed fracture to an open one with the subsequent increase infection risk. An unreduced displaced fracture may compromise the blood supply distally. Correctly to lessen these risks Bettys fracture was reduced promptly.The treatment consisted of (GP Note book, 2006)Disimpactio nManipulationImmobilisationRehabilitation in order to preserve functionThe aim of immobilisation was to allow the fracture to heal without movement of the bone ends but to facilitate as much movement of the unaffected joints as possible.An understanding of the pathophysiology of fracture helps to determine what the risk is for subsequent fracture. If this risk is high it will be advantageous to give some guard treatment to lessen this risk. The fractures with greater morbidity are hip fractures and vertebral fractures and a radial fracture may be an early warning contract of an unacceptable risk of fracture with a more serious consequence. Bone mineral density measurements may be indicated in the near future. If this is outside the normal range and taken in conjunction with the present fracture there may be a need to consider prophylactic measures against osteoporosis and further fracture.A Colles fracture is associated with subsequent hip fracture but the association is greater i n men than in women according to a metanalysis (Haentjens, 2003). Nonetheless it may be prudent to advise Betty to check with her general practitioner whether she now falls into the category of the local guideline for measuring bone mineral density. Woman with a Colles fracture within ten years of the menopause had an eight fold increase incidence of hip fracture compared with the rest of the population but the increased risk diminished by age 70 in a study by Wigderowitz (2000). In this study bone mineral density was write down in women who had a Colles fracture that in the general population but after age 66 there was no significant difference. The paper cogitate women of 65 and under presenting with a Colles fracture should undergo bone mineral density testing. Bone mineral density checking though not an exact prognosticator of subsequent fracture is a worthwhile measurement in diagnosing osteoporosis (Small, 2005). Treatments are purchasable and might be considered if osteop orosis is confirmed (McCarus, 2006). Guidelines are also available (SIGN, 2003).Oestrogen does protect bone from osteoporosis but is no longer recommended as first line prophylaxis in view of recent studies showing concern about the association with cardiovascular adverse events (Sicat, 2004). Other options include raloxifene, a selective oestrogen receptor modulator which reduces spinal but not hip fractures and biphsophonates e.g. alendronate which does reduce hip fracture incidence (British National Formulary, 2006).Action on prophylaxis would likely most easily and consistently be arranged via computerisation of letter of appointment and information to the patient following discharge. This would necessitate no increased time or resources within the department but would cover all at risk patients.ReferencesAngeli A Guglielmi G Dovio A et al 2006 High prevalence of asymptomatic vertebral fractures in post-menopausal women receiving chronic glucocorticoid therapy A cross-sectional outpatient study. Bone. 39(2) 253-9Bell M and Gillett M 1996 create reflective practice in the education of university teachers. Different Approaches Theory and perform in Higher Education. Proceedings HERDSA Conference 1996. Perth, Western Australia, 8-12 July. http//www.herdsa.org.au/confs/1996/bell.html Accessed 23 June 2006Blair S Chaudhri O Gregori A 2002 Doctor, can I drive with this plaster? An evidence based response. Injury. 33(1) 55-6.British National Formulary. 2006 British Medical Association London.Giangregorio L Papaioannou A Cranney A et al 2006 Fragility fractures and the osteoporosis care gap an international phenomenon. Semin Arthritis Rheum. 35(5) 293-305GP Notebook http//www.gpnotebook.co.uk/cache/1584070660.htm accessed 23 June 2006. Accessed 23 June 2006Haentjens P Autier P Collins J et al 2003 Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg Am 85-A(10)1936-43Hodgkinson DW Kurdy N Nicho lson DA et al 1994 ABC of Emergency Radiology the wrist BMJ 308464-468Imel S 1992 Reflective Practice in Adult Education. ERIC Digest No. 122 ED346319 http//www.ericdigests.org/1992-3/adult.htm accessed on 23 June 2006Majid and Kingsnorth 1998 Fundamentals of surgical practice. Greenwich Medical Media. LondonMcCarus DC 2006 Fracture prevention in postmenopausal osteoporosis a review of treatment options. Obstet Gynecol Surv. 61(1) 39-50Murray B Lafrenz LU 2006 The Role of Reflective Practice in Integrating Creativity in a Fashion Design Curriculum http//mountainrise.wcu.edu/archive/vol3no1/html/murraylafrenz.htm accessed 23 June 2006Netdoctor http//www.netdoctor.co.uk/diseases/facts/osteoporosistreatment.htmAccessed 23 June 2006ONeill TW Varlow J Silman AJ et al 1994 succession and sex influences on fall characteristics. Ann Rheum Dis 53(11)773-5Peters JM Jarvis P et al 1991 Adult education Evolution and achievements in a developing field of study. San Francisco Jossey-Bass. Quote d by Bell and Gillett 1996Peters JM 1991 Strategies for Reflective Practice. In R. G. Brockett (Ed), Professional Development for Educators of Adults. San Fransisco Jossey Bass. Quoted by Bell and Gillett 1996Sicat BL 2004 Should postmenopausal hormone therapy be used to prevent osteoporosis? Consult Pharm. 19(8) 725-35SIGN 2003 Scottish extramural Guideline Network 71 management of osteoporsis.Small RE 2005 Uses and limitations of bone mineral density measurements in the management of osteoporosis. MedGenMed. 2005 May 97(2) 3Wigderowitz CA Rowley DI Mole PA et al 2000 Bone mineral density of the radius in patients with Colles fracture. Journal of Bone and Joint Surgery (British) 82B 87-91