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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, gross rotational deformity, comminuted intra-articular, associated with polytrauma or other significant injuries. Fractures Patients were also excluded if the fracture angulation was greater than 70 decrease and the injury was older than one week.
  • Intervention: Buddy taping of the ring finger and little finger.
  • Comparison: Cast immobilization in an ulnar gutter cast applied in a position of safety.
  • Outcome:
    • Primary Outcome: Hand function at 12 weeks using the QuickDASH
      • QuickDASH is a validated tool to evaluate a patient’s ability to perform certain upper limb activities. DASH stands for Disabilities of the Arm, Shoulder and Hand. The original questionnaire has 30 items while the QuickDASH has only 11. The patient reports their functional ability on a 5-point Likert scale. The patient’s overall disability is rated between 0 and 100. The higher the score, the greater the disability. The minimal detectable change (MDC) is 11% while the minimal clinical important difference (MCID) is 8%.
    • Secondary Outcomes: Pain, satisfaction, return to work, return to sports, and quality of life.

Authors’ Conclusions: “We found that patients with boxer’s fractures who were randomized to buddy taping had functional outcomes similar to those of patients randomized to plaster cast at 12 weeks. We advocate a minimal intervention such as buddy taping for uncomplicated boxer’s fractures.”

Quality Checklist for Randomized Clinical Trials:

  1. The study population included or focused on those in the emergency department. Yes
  2. The patients were adequately randomized. Yes
  3. The randomization process was concealed. Yes
  4. The patients were analyzed in the groups to which they were randomized. Yes
  5. The study patients were recruited consecutively (i.e. no selection bias). Unsure
  6. The patients in both groups were similar with respect to prognostic factors. Yes
  7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
  8. All groups were treated equally except for the intervention. Yes
  9. Follow-up was complete (i.e. at least 80% for both groups). No
  10. All patient-important outcomes were considered. Yes
  11. The treatment effect was large enough and precise enough to be clinically significant. Unsure

Key Results: They assessed 506 patients for eligibility with 126 randomized. The mean age was in the mid-twenties, 85% were male and 90% were right hand dominant.

No statistical difference in the QuickDASH score between buddy tape and plaster casting.

  • Primary Outcome: Median QuickDASH score at 12 weeks
    • 0 buddy tape vs. 0 plaster cast (95% CI; 0 to 0)
  • Secondary Outcomes: 
    • Pain – Both groups reported absence of pain at 12 weeks
    • Satisfaction – Both groups reported high satisfaction scores with treatment
    • Return to Work – Buddy tape patients missed no days of work while those in a cast missed a median of two days of work
    • Return to Sports – No difference between the two groups
    • Quality of Life – No difference between the two groups 

1. Selection Bias: There is a possibility of selection bias. There were 41 eligible patients who were not recruited and 34 who declined to participate. The patients who were missed were because the emergency department was too busy and there were other clinical priorities.  The demographics of the missed patients were similar to the included patients suggesting that selection bias would be unlikely.

2. Loss to Follow-Up: One quality indicator is whether or not there were more than 20% of patients lost to follow-up. They reported 21% of patients being lost to follow-up (18% in the buddy tape group and 23% in the plaster cast group). This threatens the validity of the conclusions.

3. Non-Inferiority Trial: This was designed as a superiority trial. The real question could have been: is buddy taping non-inferior (not worse) that casting. A smaller sample size would be needed to demonstrate non-inferiority. This should help with nerdy point #5 about replication.

4. QuickDASH: We had some questions and concerns about the QuickDASH assessment tool. It’s reliability is 0.9 and its validity is 0.7. This could have an impact of the precision of the results.

5. Replication: This study would need to be replicated in other healthcare systems for external validity. The patient population is probably the same, but their expectations may be different. What impact would this have on emergency department length of stay and cost. Would local specialists agree with such a change in management?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree that they demonstrated buddy taping had similar functional outcomes to plaster casting in patients with a boxer’s fracture. However, we would not advocate for buddy taping uncomplicated boxer’s fractures at this time based on one RCT.

SGEM Bottom Line: Consider offering patients with uncomplicated boxer’s fractures buddy taping.

Case Resolution: You inform him there is another treatment option called buddy taping and in form him of the limitations of the evidence. He decides to try buddy taping instead of a plaster cast.

Ulnar Guttar

Clinical Application: This small trial provides some evidence that buddy taping uncomplicated 5th metacarpal fractures is reasonable. It is not enough to change my routine practice of putting patients in an ulnar gutter. The orthopedic surgeon or plastic surgeon can decide how to manage these patients once they see them in clinic. If the patient requests not having a cast, I will bring up the buddy taping idea. We think this type of treatment needs to be validated and confirmed before offering this routinely to patients.

Buddy Taping

What Do I Tell My Patient? There is another option besides casting. One small study of less than 100 patients done in Australia put half the people in casts and half of them had their 4th and 5th finger buddy taped together. Both groups had the same functional outcome at three months. The study needs to be confirmed here and our hand surgeons need to be on board. The traditional way is still to cast these broken bones. Let me know If you really want to try buddy taping.

Keener Kontest: Last weeks’ winner was Rachel Bridwell from San Antonio, Texas. She knew the first head CT was performed in 1971. It was not publicized until a year later.

Listen to the podcast to hear this weeks’ trivia question. If you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Martha and Ken (Buddies)