SGEM#273: My Buddy (Tape) for Boxer’s Fractures

Date: October 29th, 2019 Reference: Pellatt et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of EM 2019 Bootcamp Buddies Guest Skeptic: Martha Roberts is a critical and emergency care, triple certified nurse practitioner, currently living and working in western Massachusetts. She is the host of EM BOOTCAMP in Las Vegas, as well as a usual speaker and faculty member for The Center for Continuing Medical Education (CCME). She writes a blog called The Procedural Pause for Emergency Medicine News and is the lead content editor and director for the videos series soon to be included in Roberts & Hedges Clinical Procedures in Emergency Medicine. Martha also serves as an adjunct professor for both Georgetown University and Marymount University in the Washington D.C. area. We thought about using Simon and Garfunkel’s song “The Boxer” but  later decided to use “My Buddy” song by Anne Murray. “The Boxer” was one of the most highly produced songs by Simon and Garfunkel. The song is the single of and is featured on the album Bridge over Troubled Water released in May,1969. It was written by Paul Simon as he laments about being criticized by the public.  The song also features a bass harmonica and a Moog synthesizer. The song made it to the Rolling Stones list of top 500 songs of all time as #106. Case: A 26-year-old right-handed male presents to the emergency department on Friday night with a swollen right hand after punching a wall.The x-ray confirms an uncomplicated boxer’s fracture. You explain to him the traditional management which includes adequate pain control, immobilization with a cast and referral to a hand surgeon. He does not want any opioids because a friend was addicted to oxycocet. He is fine with going to see a hand surgeon in clinic, but asks if he really needs a cast. He is concerned that it will interfere with going to work on Monday morning. Background: Boxer’s fractures are common hand injuries. They are usually due to punching a solid object with a closed fist. For clarity, in this SGEM episode: when we say boxer’s fracture, we are referring to a fracture of the neck of the fifth metacarpal. There has been some controversy on the best way to manage an uncomplicated boxer’s fracture. This is typically defined as a minimally displaced closed fracture with angulation up to 70 degrees. Poolman et al (Cochrane 2005) did a SRMA and pooled together five studies with a total of only 252 patients. Most of the studies were of poor quality and functional outcome was not used in any of the studies. Because of the lack of good evidence, no treatment modality could be recommended over another. Another systematic review meta-analysis was done by Dunn et al (Orthopedics 2016). They found that cast immobilization is not superior to soft wrap without reduction in most cases. No study had investigated whether or not buddy taping would be superior to casting for functional outcomes in patients with boxer’s fractures. Clinical Question: Is buddy taping an uncomplicated boxer's fracture just as effective as a plaster cast? Reference: Pellatt et al. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial. Annals of EM 2019 Population: Adults (18-70 years of age) with uncomplicated fractures of the fifth metacarpal neck (boxer’s fracture). Uncomplicated Fractures: These were defined as fractures confirmed by radiograph with at least two views showing a closed fracture (NOT comminuted, NOT intra-articular) with fracture angulation less than 70 degrees, less than one week old, did not have tendon involvement and with no polytrauma or other significant injury. Excluded: Patients less than 18 years of age or older than 70 years. Fractures that were open,