Saturday 29 June 2019

Buddy taping vs. Plaster for Neck of 5th Metacarpal (Boxer’s) Fractures

I love saving time in the ED. Much of this can come from avoiding procedures that don’t provide benefit to the patient.

Should we dump plaster casting for Boxer’s fractures?

This was an RCT from Queensland, Australia. Evidently, they do a lot of punching in Queensland.

They included patients between 18-70 years old, simple closed fractures without rotation and an angulation of less than 70 degrees. Yes, you read that correctly, they tolerated up to 70 degrees.

126 patients were randomised to buddy taping or plaster cast immobilisation.

The primary outcome was hand function at 12 weeks using the quickDASHquestionnaire. They also looked at pain, satisfaction, return to work or sport, and quality of life.

As expected with this cohort of patients, there were quite a few lost to follow up and 97 patients underwent intention to treat analysis.


At twelve weeks, both groups were the same on the quickDASH questionnaire. Those randomised to buddy taping returned to work earlier than those in the plaster group. Other measures were also similar. Ultimate fracture angle at follow up was similar at about 30 degrees.

The authors conclude, “we advocate a minimal intervention such as buddy taping for uncomplicated boxer’s fractures.”

However, there were several limitations to this study. It was not blinded which could have introduced bias. The study design should have really been a non-inferiority trial.

But there may have been a bigger issue.

The quality of the conclusion is only as good as the validity of the primary outcome measure. I’m not convinced that the quickDASH questionnaire is robust enough to reliably measure the big picture. In addition, capture of data may not have been the most discerning; thus pushing the conclusions towards the null hypothesis.

In the end, our referring doctors (ortho, plastics, or hand specialists) are going to dictate their preferences to us. Given the overall quality of the evidence, I don’t have a problem doing what they like.

My local hand specialists have asked us to continue with plaster immobilisation. They feel you can get a better reduction using the Jahss technique, have less initial pain, less narcotic use and possibly require less operative reduction. Of course, this is an eminence-based recommendation. If I moved to Queensland, I will probably be buddy taping... and watching my back. 


Pellatt R, Fomin I, Pienaar C, et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Ann Emergency Med. 2019; 74:22-97. [link to article]

Early vs. Delayed Cardioversion in Recent onset of Atrial Fibrillation

We know from prior studies that acute atrial fibrillation will frequently spontaneously revert. So, when patients arrive to the ED, which is better? Immediate cardioversion or a “wait-and-see" approach.

To attempt to answer this question, these Dutch investigators conducted a multicentre randomised noninferiority trial. They enrolled stable patients with recent onset (less than 36 hours) to early cardioversion vs. wait-and-see.

The wait-and-see approach involved giving rate control medications and eventual cardioversion if the AF was not resolved by 48 hours.  

The primary endpoint was the presence of sinus rhythm at 4 weeks. However, there were other important secondary measures they captured such as rate of spontaneous resolution, resource utilisation, recurrence of AF, safety etc.


By 4 weeks both groups were about the same and within their prespecified non-inferiority margin. Sinus rhythm was present in 91% of the delayed group vs. 94%.

So, it doesn’t matter?

Perhaps it does… In the delayed group, the rate of spontaneous resolution was 70%! This begs the question, why do we bother with such an early aggressive approach to AF when it very often spontaneously resolves.  Can we limit the potential harms of antiarrhythmic medications and procedural sedations and let nature take its course?

These findings are consistent with prior researchDoyle B et al. Heck, I may not ever get published in the NEJM but at least I have been referenced! 

What do I do?

This is the time for shared decision making. Pull up a chair and have a chat to the patient.  It also depends on how symptomatic the patient is, their prior experiences, rates of recurrence, and dare I say, a busy department.

Quick… don’t just do something, stand there!


Pluymaekers N, Crazy Dutch Name, Dudink J, Luermans J, et al. Early or Delayed Cardioversion in Recent-Onset of Atrial Fibrillation. N Engl J Med 2019;380:1499-1508. [link to article]

Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke: how fragile can we be?

The biggest, baddest controversy in Emergency Medicine just got worse.

Yes, it’s stroke lysis.

This multicentre RCT enrolled adult patients in whom alteplase or placebo could be given between 4.5 to 9 hours after onset of stroke or on awakening with stroke symptoms. A prerequisite for inclusion was a perfusion deficit (area of ischemic but not infarcted brain) on CT or MRI.

The primary outcome was a score of 0-1 on a modified Rankin scale (mRS) adjusted for age and baseline severity of stroke. Of course, they looked at many secondary outcomes including the classic ordinal shift analysis and some safety measures.

They estimated a sample size of 400 patients would be needed in order to have 80% to detect a difference of 15% in the primary outcome.

Recruitment was slow going. They only enrolled 225 patients over 8 years in in 28 centres! That’s about one patient per centre per year! Yikes. No wonder they called it quits early. They claimed the WAKE-UP trial published in May 2018 caused them to lose clinical equipoise and they terminated early. I think they probably had enough anyway…


40 (35%) patients in the alteplase group were mRS 0-1 vs. 33 (29.5%) in the placebo group (adjusted risk ratio, 1.44 95% confidence interval 1.01 to 2.06; P=0.04). Symptomatic ICH was 6% vs. 1%.

Thrombolysis is a winner!??!!

Unfortunately, it is not so clear.

There was no statistical difference in the primary outcome when they used their originally proposed logistic regression modelling rather than a different method introduced during recruitment. The unadjusted analysis; no difference. There was no difference in the ordinal shift analysis (which ironically was touted as the saviour of IST-3). But most of all, the results are just plain fragile.


The fragility index was less than one. Put another way, if one less patient in the alteplase group did not meet the primary outcome, the trial would have been negative. This seems far from a definitive trial.

The authors claim that “further trials of thrombolysis in this time window are required.” This seems rather contradictory when they claim to have stopped their trial due to lack of clinical equipoise.

What to think?

If I was calling the shots, I would not extend my window. But at the same time, others may interpret this study differently. 

However, much of this might be a storm in a teacup. The vast majority of patients in this window derive neither harm nor benefit from thrombolysis (NNT 17 if you believe the results). In addition, clot retrieval is all the rage now.  


Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. N Eng J Med 2019;380:1795-803.[link to article]