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.
Results?
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.
Covering:
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]
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