Reflexive Practice in Bone Fractures

Reflective practice was carried out on a case of boxer’s fracture to the right hand at the minor injury unit. Gibb’s Reflective Cycle (Gibbs, 1988) was used to aid the reflective process and to assist with critical evaluation of recent evidence on the assessment and management of boxer’s fracture. Gibb’s reflective model comprises of 6 stages: description, feelings, evaluation, analysis, conclusions, and action plan (Finlay, 2008).

A 28-year-old patient presented with an injury to the right hand after punching a wall with anger.

The patient complained of severe pain in the fifth metacarpal and heard a “crunching” sound when hitting the wall. The patient was allergic to penicillin, had no prior medical history of note, and denied substance abuse, was a non-smoker, and drank alcohol socially. The patient worked at a factory and was right-handed.

On examination, the patient’s right hand was swollen, with tenderness noted over the fifth metacarpal, accompanied by weakness with finger flexion. An x-ray of the right hand revealed an uncomplicated fifth metacarpal transverse neck fracture with minimal angulation (50 degrees). Lacerations over the metacarpophalangeal joint were not visible and fight bite was ruled out. There was no rotational deformity. The patient was managed by ice application, elevation, and analgesia. The fifth finger was then strapped to the ring finger. The patient was discharged home on the same day with analgesia (ibuprofen 200mg 8 hourly), an arm sling (for elevation), and an orthopaedic outpatient follow-up appointment in 1 week.

This was the first time I came across boxer’s fracture, which motivated me to reflect. Patients presenting with hand injuries usually involve metacarpal neck fractures (commonly the fifth metacarpal) (Toemen and Midgley, 2010; Jones et al., 2010). These fractures are usually referred to as boxer’s fracture (Altizer, 2006; Bragg, 2005), but are not usually associated with professional boxers (Soong, Got and Katarincic, 2010).

Critical Evaluation of Evidence (Evaluation and Analysis)

As part of the reflective process, I carried out a literature search using the MEDLINE and CINAHL databases for recently published articles on the assessment and management of fifth metacarpal fractures, also known as boxer’s fractures. For more details regarding the search strategy, refer to Appendix 1.

Four recently published literature reviews were included. Keenan (2013), examined management strategies of closed fractures of the fifth metacarpal. After a through literature search, the author proposed a detailed care pathway for boxer’s fracture in the emergency department to provide continuity of care. Alton (2019) assessed the importance of properly evaluating closed-fist injuries, especially with regards to identification of fight bites. Kollitz et al. (2014), discussed the non-operative management of stable fractures and compared existing literature on treatment methods and complications of different acute metacarpal fractures. Finally, Giddins (2014), identified and discuss hand fractures that can be successfully treated without surgery.

Assessment and Diagnosis

Alton (2019) and Keenan (2013) discussed the assessment and diagnosis of patients presenting with boxer’s fracture. Keenan (2013) stated that initial steps should include taking a subjective history and performing an objective examination. A subjective history should include patient’s age, job, injury mechanism, hand dominance, presence of peripheral neuropathy or other numbness, and history of previous fractures to the hand. During examination, nurses should assess for tenderness and swelling of the fifth metacarpal, rotational deformity, tendon, nerve, and vascular function, and whether the injury is open or closed.

Alton (2019) agreed that assessment should begin by careful inspection of the hand, establishing hand dominance, and observing for gross deformities. Alton (2019) points out that the skin over the metacarpal bones should be examined for abrasions and lacerations which are typical of fight bites. Certain patients may be reluctant to provide an accurate history of fight bites (due to involvement of physical altercation), but a fight bite injury must be ruled out during initial assessment.

In addition, nurses should perform a neurovascular assessment and observe colour, temperature, pulses, and sensation, which should be the same as non-affected areas. Hand function should then be evaluated by assessing active range of motion of the affected hand and fingers. If the patient is unable to do this, range of motion should be passively assessed by asking the patient to make a fist and straightening the fingers for assessment of extensor tendon damage. Finger alignment should be assessed for misalignment or malrotation. This is done by asking the patient to make a fist and then turning the hand over to examine the ventral surface and to check finger alignment. Both hands need to be evaluated simultaneously and compared to one another. Finger alignment may also be checked by assessing the fingertip pads at full extension and checking whether the fingernails are aligned by comparing with the unaffected hand (Alton, 2019).

In the patient from the case study, a subjective history was taken, and an objective examination was performed. However, the latter was not as thorough as suggested by the published literature, and although fight bite was ruled out, the patient’s hands were not evaluated simultaneously or compared to one another, and range of motion was not assessed. This was one of the negative aspects in this situation with regards to patient assessment.

Initial management for boxer’s fracture should include pain management by administration of analgesia (co-codamol and/ or ibuprofen), support using a high arm sling, a hand x-ray (initially anteroposterior and oblique views, and if boxer’s fracture is confirmed, a lateral view), and a post-x-ray review to identify the degree of palmar angulation (Keenan, 2013). The hand should be elevated to minimise swelling for as long as needed, depending on whether surgery will be performed (Alton, 2019). Further management should then be based depending on the type of fracture (Keenan, 2013).

According to Keenan (2013), in cases of a closed fracture without rotational deformity and associated injury, and with palmar angulation of less than 70 degrees, the following should be performed: neighbour strapping (also referred to as buddy splinting or taping) for 1 week, a high arm sling, protection, rest, ice, compression, and elevation. In these cases, the patient may be discharged home without a follow-up appointment and an education leaflet on boxer’s fracture should be provided (Keenan, 2013). Alton (2019) also agreed that uncomplicated (transverse) fractures without fight bite can be splinted and evaluated by a hand specialist within 2 to 5 days.

Furthermore, splinting may range between 2 and 6 weeks and timely x-rays (e.g., week 2, week 6, month 3 following injury) should be performed to ensure adequate healing and alignment (Alton, 2019). Fight bites may require antibiotic treatment and should be splinted in an anatomical position and re-evaluated within 24 hours (Alton, 2019). Kollitz et al., (2014) stated that non-surgical techniques may include buddy taping of the fifth finger to the ring finger with immediate mobilisation or 4 weeks of immobilisation using a cast or splint (Kollitz et al., 2014). Duration of immobilisation would depend on tenderness on clinical assessment. Furthermore, positioning of the metacarpophalangeal joints during immobilisation does not affect overall outcomes (range of motion, grip strength, and aesthetics) (Kollitz et al., 2014).

In cases of a closed fracture without rotational deformity and associated injury and with palmar angulation of more than 70 degrees, Keenan (2013) recommends administering a metacarpal block, followed by reduction of fracture, application of an ulnar gutter back slab and high arm sling, and a post-reduction lateral-view x-ray. The patient may be discharged home with a follow-up appointment within 7 days.

In the patient from the case study, a hand x-ray was taken, and the patient was administered analgesia. The patient’s hand was also elevated to decrease swelling and ice was applied. Since the patient had a closed fracture without associated injury and with minimal angulation, neighbour strapping was performed, and the patient was discharged with a follow-up appointment within 1 week. These activities were all in line with what is suggested by the literature. However, a patient information leaflet and patient education were not provided by the nurse, which was another negative aspect in this case.

In more serious cases involving closed fractures with intra-articular involvement or which are comminuted, or with rotational deformity and neurovascular compromise, or in cases of an open facture; the patient must be referred to an on-call orthopaedic team (Keenan, 2013). Open fractures require admission to an orthopaedic ward, tetanus immunisation, application of a temporary sterile dressing, and intravenous antibiotics (co-amoxiclav 1.5g or a suitable alternative in cases of penicillin allergy, and metronidazole 500mg), along with a high arm sling (Keenan, 2013). Closed fractures with rotational deformity and neurovascular compromise may be managed with metacarpal block, fracture reduction, ulnar gutter back slab, high arm sling, a post reduction lateral view x-ray, and re-assessment of neurovascular status.

Further treatment and decision to admit or discharge is usually made by the on-call orthopaedic team for closed fractures with intra-articular involvement or which are comminuted and for closed fractures with rotational deformity and neurovascular compromise (Keenan, 2013). Alton (2019) adds that if scissoring (one finger overlapping another, also referred to as malrotation) is evident, then reduction is usually required. Malrotation would usually require surgery and should be referred to an orthopaedic hand specialist. Failing to correct malrotation may result in chronic pain and loss of grip. Kollitz et al., (2014) also agreed that surgical indications include malrotation and unstable fractures. Possible complications of surgery may include loss of knuckle prominence, stiffens, and extension lag (Kollitz et al., 2014).

Thankfully, the patient in the case study did not sustain serious injury and could be managed without surgery. The patient’s penicillin allergy must be noted, however, since this would require careful attention should a need for antibiotic administration arose.

Positive outcomes of non-surgical treatments have been widely reported in the literature. Most fifth metacarpal neck fractures demonstrate good outcomes with non-surgical management due to a substantial tolerance for shortening and angulation (Kollitz et al., 2014). Functional outcomes are usually excellent, aside from mild cosmetic abnormalities. Furthermore, no single non-surgical technique has been shown to be superior over another (Kollitz et al., 2014; Giddins, 2014). Many surgical techniques have been described, including intramedullary nailing, k-wire (bouquet) fixation, intraosseous loop wire fixation, and external fixation. Results with these techniques did not demonstrate better reliability than non-surgical techniques.

Furthermore, surgical methods are associated with several complications which are not seen with non-surgical management (Giddins, 2014). Kollitz et al., (2014) and Giddins (2014) both cited a study by Westbrook et al., (2008) which found no significant differences between patients treated by surgical and non-surgical methods, although data favoured the non-surgically managed group. After a follow-up of 2 years, no significant differences were seen with regards to Disabilities of the Arm, Shoulder and Hand (DASH) Score, grip strength, or aesthetics between the two groups. There was, however, a significant complication rate in the surgical groups which was not seen in the non-surgically managed group (Westbrook et al., 2008).

Kollitz et al. (2014) also cited a study by Harris et al. (2009), in which the authors concluded that since fifth metacarpal neck fractures are usually stable, traction reduction and cast immobilization show positive results, with up to 81% improvement in angulation (Harris et al., 2009). The patient’s stable fracture which had no significant angulation and no evidence of fight bite was managed non-surgically as seen in the case study. Overall patient management therefore correctly aligned with recommendations in recently published literature.

The included literature was recently published and contained up-to-date evidence on the assessment and management of patients with boxer’s fracture. Most authors (Alton, 2019; Giddings, 2014; Kollitz et al., 2014) discussed the management of various hand injuries and only one (Keenan, 2013) focused solely on the assessment and management of boxer’s fracture. In fact, Keenan (2013) focused on a detailed care pathway for patients presenting to the emergency department with boxer’s fracture. Implementation of such care pathways will facilitate the nursing care and management of patient presenting with such cases.

After reflecting on this specific case which I encountered during my placement and after analysing the most recent published evidence. I am not able to understand the importance of taking a subjective history and of performing an objective examination (Keenan, 2013) which should include ruling out fight bite injury and assessment of active range of motion of the affected hand and fingers (Alton 2019). In addition, both hands need to be evaluated and compared.

Patient education should be a nursing priority, and in cases of boxer’s fracture, this should include the provision of an education leaflet especially in patients who do not require hospital admission and are sent home on the same day (Keenan, 2013). When clinicians are more alert and are able to recognise cases suggesting boxer’s fracture or fight bite, accurate diagnosis and effective treatment could be achieved which will significantly improve patient outcomes (Alton, 2019).

References

1. Altizer, L. (2006) Boxer's fracture. Orthopaedic Nursing, 25(4), pp.271-273.
2. Alton, S. and Carayannopoulos, N. (2019) Hand injuries: boxer fractures and fight bites. The Journal for Nurse Practitioners, 15(5), pp.334-338.
3. Bragg, S. (2005) The boxers' fracture. Journal of Emergency Nursing, 31(5), p.473.
4. Finlay, L. (2008)?Reflecting on 'reflective practice'. [ebook] The Open University. Available at: http://www.open.ac.uk/opencetl/files/opencetl/file/ecms/web-content/Finlay-(2008)-Reflecting-on-reflective-practice-PBPL-paper-52.pdf [Accessed 2 Nov. 2019].
5. Gibbs, G. (1988)?Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Polytechnic.
6. Giddins, G. (2014) The non-operative management of hand fractures. Journal of Hand Surgery (European Volume), 40(1), pp.33-41.
7. Harris, A., Beckenbaugh, R., Nettrour, J. and Rizzo, M. (2008) Metacarpal neck fractures: results of treatment with traction reduction and cast immobilization. Hand, 4(2), pp.161-164.
8. Jones, R., Burdett, S., Jefferies, M. and Guha, A. (2010) Treating the boxer's fracture in Wales: a postal survey. The Annals of The Royal College of Surgeons of England, 92(3), pp.236-239.
9. Keenan, M. (2013) Managing boxer’s fracture: a literature review. Emergency Nurse, 21(5), pp.16-24.
10. Kollitz, K., Hammert, W., Vedder, N. and Huang, J. (2013) Metacarpal fractures: treatment and complications. Hand, 9(1), pp.16-23.
11. Soong, M., Got, C. and Katarincic, J. (2010) Ring and little finger metacarpal fractures: mechanisms, locations, and radiographic parameters. The Journal of Hand Surgery, 35(8), pp.1256-1259.
12. Toemen, A. and Midgley, R. (2010) Hand therapy management of metacarpal fractures: an evidence-based patient pathway. Hand Therapy, 15(4), pp.87-93.
13. Westbrook, A., Davis, T., Armstrong, D. and Burke, F. (2008) The clinical significance of malunion of fractures of the neck and shaft of the little finger metacarpal. Journal of Hand Surgery (European Volume), 33(6), pp.732-739.

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