Introduction The reflective framework chosen for this case study is that of Peters (1991). This framework has been used and favourable evaluated within education (Bell and Gillett, 1996). Peters’ (1991) reflective framework incorporates a guideline called DATA comprising four steps;
The first step is the description of an aspect of practice the clinician wants to change. Identification would be made of the context and the reason the clinician wants to change the practice and their feelings about this. Analysis involves identification of the factors that lead 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 the action putting the new theories (if appropriate) into practice to ensure that such cases continue to be managed appropriately in the future. “Success of this process would occur only through additional thought and reflection” (Murray, 2006).
At 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 confidentiality, that was not her real name. She had been brought to the department by car by her husband.
Betty was seen by the triage nurse and subsequent upon waiting her turn was allocated a cubicle. I saw her at 11.20 hours.
An understanding of the pathophysiology of fracture is important if important aspects of the patient’s history are not to be missed. Firstly taking an adequate history of the accident, including details of the mechanism of the fall, will help the clinician to decide whether the amount of force applied to the bone would be of the degree that would be expected to cause that particular fracture. Secondly there may be underling osteoporosis leading to fracture 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 fracture which occurs after only minimal trauma and from a standing height or less, the degree of trauma being that which would not normally be expected to fracture healthy bone, may be what is known 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. In the absence of such a clear history other 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.
On inspection Betty’s right wrist was swollen. The skin was intact. There was some distortion of the normal contour of the arm typical of a “dinner 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 movements. The preliminary diagnosis of Colles fracture was made with some degree of confidence since the patient was a 64 year old female who had fallen on an outstretched and had classic examination findings of such a common injury.
For 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 elbow.
X ray examination of Betty’s 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.
Analgesia 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 reduced and manipulated and then immobilised. Betty chose to have a general anaesthetic for this procedure.
To disimpact the fracture Betty’s hand was pulled distally whilst her wrist was hyper extended. Once disimpaction 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 plaster 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 immobilisation in fracture are joint stiffness and tissueand especially muscle, atrophy. An important and serious complication is Sudek’s 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 arranged 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.
On analysis of the case presentation it is apparent that the well known clinical features of a fracture were present;
as were the five classical features of a Colles fracture, often called the “dinner fork deformity” (GP Notebook, 2006);
- Dorsal displacement of distal fragment
- Distal fragment dorsally angulated
- Hand deviated towards the thumb
- Wrist joint supinated
- Proximal impaction
The absence of crepitus might 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 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 distal 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 healing. 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 found 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 emergency 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 (O’Neill, 1994).
There is an assumption that the risk 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.
Fracture healing is affected by general and local factors (Majid and Kingsnorth, 1998). The general factors include the patient’s 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 prejudice 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 Kingsnorth, 1998);
- Inflammatory phase
- Repair phase
- Remodelling phase
In 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 agreement with the formulation of guideline for information giving to both patient and general practitioner. Ideally an appointment would be generated for the bone mineral density scanning and reporting and advising. A mechanism of patient information will be required in parallel.
DATA Actions proposed
The aims of the proposed action were to achieve;
- Healing of the bone, and
- Preservation 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.
If the fracture is displaced this may, if left untreated, lead to breach of the overlying skin and convert a closed fracture to an open one with the subsequent increased infection risk. An unreduced displaced fracture may compromise the blood supply distally. Correctly to lessen these risks Betty’s fracture was reduced promptly.
The treatment consisted of (GP Note book, 2006);
- Rehabilitation in order to preserve function
The 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 prophylactic 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” sign 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 in 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 lower in women who had a Colles fracture that in the general population but after age 66 there was no significant difference. The paper concluded women of 65 and under presenting with a Colles fracture should undergo bone mineral density testing. Bone mineral density checking though not an exact predictor of subsequent fracture is a worthwhile measurement in diagnosing osteoporosis (Small, 2005). Treatments are available and might be considered if osteoporosis 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.
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