Case Study: Fractured Hand

episode Study Fractured HandIntroduction The horizonful framework chosen for this geek study is that of Peters (1991). This framework has been handlingd and favour up to(p) evaluated within education (Bell and Gillett, 1996). Peters (1991) reflective framework incorporates a guideline c wholeed discriminating information comprising cardinal steps get outAnalyseTheorizeActionThe eldest step is the description of an scenery of practice the clinician wants to mixture. Identification would be made of the context and the reason the clinician wants to change the practice and their feelings around this. Analysis involves identification of the factors that blend in to and the assumptions that support the place approach. This includes depth psychology of beliefs, rules and motives supporting the inaugurate approach (Imel, 1992). Theorizing is the next step which looks at the theories for developing a untested approach building on the theories that were place that were suppor ting the present approach. The final step is the action putting the new theories (if appropriate) into practice to ensure that such lessons continue to be managed appropriately in the future. Success of this process would occur only through additional thought and reflection (Mur beam of light, 2006).DATA DescriptionPatient presentationAt 11 am a 64 year old lady presented to the hap and Emergency Departwork forcet with a painful right carpus next a peg. We shall call her Betty but, in order to protect confidentiality, that was not her authorized name. She had been brought to the discussion section by car by her husband.Patient assesswork forcet business relations hip jointBetty 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 separate is definitive if all-important(prenominal) grimaces of the longanimouss history are not to be missed. Firstly pickings an fair to middling history of the accident, including details of the machine of the go along, go out help the clinician to purpose whether the amount of force applied to the b maven would be of the degree that would be judge to cause that particular work shift. Secondly there whitethorn be underling osteoporosis leading to dampen with minimal trauma. at that place may be factors in the history suggestive of osteoporosis e.g. use of systemic steroids (Angeli, 2006) or wee menopause without subsequent horm cardinal replacement therapy. A break which occurs afterwards only minimal trauma and from a standing h cardinal or less, the degree of trauma being that which would not normally be expected to chemise healthy organise, may be what is known as a fragility kick downstairs. This occurs where a tog up is weakened by a morbid process , (Majid and Kingsnorth, 1998) such as osteoporosis. In distinction a pathological get out occurs because of metastatic bone disease. Thirdly no t just the mechanism of the fall but the reason for the fall call for to be considered. Betty had slipped on some ice when walking outside to her car. In the absence seizure of such a clear history other factors in the history should be considered for instance funny turns, visual hassles, cerebrovascular accidents, or non accidental injury. It is important to directly enquire about that last aspect.ExaminationOn revaluation Bettys right wrist was swollen. The skin was intact. There was some torture of the normal contour of the arm typical of a dinner house crack. The distal part of the rundle was angulated dorsally, the wrist supinated and the hand deviated towards the flip. On palpation the distal radius was markedly tender. There was no crepitus. Betty was unable to use her right arm at all. The stellate and ulnar pulses were readily touchable and there was good capillary refill in the hand. Sensation in the radial, ulnar and median nerve dermatomes was normal as were f inger and thumb movements. The preliminary diagnosis of Colles shot was made with some degree of effrontery since the patient was a 64 year old female who had move on an outstretched and had classic examination findings of such a joint injury.InvestigationsFor a completely confident diagnosis a plain X ray was required. For an X ray of a suspected crack cocained limb the spare-time activity are requirements (Majid and Kingsnorth, 1998)The X ray should be in two incompatible designinges at right angles.The X ray should involve the joint preceding(prenominal) and below the suspected crush site. In this case the wrist and the elbow. diagnosisX ray examination of Bettys arm revealed a cross(prenominal) extra articular offer of the distal radius within one inch of the wrist joint. The distal radial fragment was displaced dorsally. A Colles fracture could now be distinguishd with confidence.ManagementAnalgesia was given by intra muscular injections of morphine 10 mg and stem etil 12.5 mg. The arm had been temporarily immobilised with a splint and tall 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 get a usual anaesthetic for this procedure.To disimpact the fracture Bettys hand was pulled distally whilst her wrist was hyper lengthy. Once disimpaction had been achieved the wrist was manipulated so that it was flexed with some ulnar digression and pronation. In this slip it was immobilised by a smear 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 transversal 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 affirmation Betty was advised to wear her right arm in a slingshot 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 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 squeeze out 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 conquered get marrieding 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 fra cture 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 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 initial 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 o f the radius.Sometimes a Colles fracture is associated with a fracture of the ulnar styloid (GP Notebook, 2006) and this must be seek 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 heal. Another injury also caused by a fall on the outstretched hand and which it is important not to miss is a fractured navicular (Hodgkinson, 1994). This is clinically characterised by tenderness in the anatomical snuff cuff 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 crippling avascular necrosis. Other injuries corporation 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 a rea 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 video display that those individuals with fragility fractures seldom received investigation or treatment of osteoporosis (Giangregorio, 2006). The author 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 untrue that because postmenopausal women are lacking in oestrogen and therefore incline to osteoporosis that is the only rea son. However research has shown that women have more move 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 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. preclusive measures may be a neglected but important aspect of the accident and emergency role despite resources being an ever restraining factor.DATA TheorizingFracture heal 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 prejudice healing. Loc al 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 varietyRepair legRemodelling phaseIn the inflammatory phase haematoma contains osteoclasts which remove dead bone. everywhere 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 ugly 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 two 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 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 use was required. During manipulation it was important to pull the hand in order to disimpact the fracture. function then involved a reversal of the position that was present reservation up the dinner fork deformity.ManagementIf 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 change magnitude in fection 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)DisimpactionManipulationImmobilisation reformation 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 coiffure what the risk is for subsequent fracture. If this risk is high it will be profitable to give some prophylactic treatment to lessen this risk. The fractures with greater morbidness 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 interpreted in conjunc tion 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. cleaning lady 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 state 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. Bo ne mineral density checking though not an exact predictor of subsequent fracture is a worthwhile measurement in diagnosing osteoporosis (Small, 2005). Treatments are open and might be considered if osteoporosis is confirmed (McCarus, 2006). rule of thumbs 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 internal 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 co ver all at risk patients.ReferencesAngeli A Guglielmi G Dovio A et al 2006 full(prenominal) prevalence of asymptomatic vertebral fractures in post-menopausal women receiving chronic glucocorticoid therapy A cross-section(a) outpatient study. Bone. 39(2) 253-9Bell M and Gillett M 1996 Developing reflective practice in the education of university teachers. Different Approaches Theory and Practice in Higher Education. transactions 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. 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