Cost-Effective Management of Volar Plate Injuries

Cost-Effective Management of Volar Plate Injuries: A Quality Improvement Study on Hand Therapy Techniques

[Name of Student]

[Name of Property]

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Abstract

Hand therapy plays a crucial role in the treatment of hand injuries or volar disc injuries. It is often seen in the clinical setting due to a hypertensive point in the interphalangeal joint (PIP). As mentioned, there are well presented approaches for surgical fixation; However, the role and hand therapy guidelines are still not very clear. The aim of the project is to improve efficiency and reduce costs due to multiple appointments and splinters in the manual therapy department. This study used a positive, quantitative approach to objectively determine the most effective and cost-effective manual technique. A retrospective cross-sectional design was used when questionnaires were used to collect retrospective information on patients treated as outpatients within the past year. This allowed the clinical results and costs of different treatments to be compared over time. This made it possible to collect a larger sample through questionnaires. Quantitative analysis of patient-reported numerical results provided an objective method of measurement. Previous similar studies have used this retrospective cross-sectional design to effectively compare different treatments while controlling for injury severity. This cross-sectional study used questionnaires distributed in the previous year to patients treated for volar disc injuries in the outpatient department of a large urban hospital in the United Kingdom with a population of over 500,000. All patients aged 13 years and older treated for open disc injuries in an outpatient hand clinic during a year (N=54) participated in this study. As both chi-square and Anova showed significant results, this provides strong evidence that the type of treatment modality affects both clinical outcomes and time to release. Thus, based on these two criteria, it can be concluded that one treatment method may be more effective than the other.

Chapter 1: Introduction

Background 

Hand therapy has a crucial role in the management of hand injuries i.e. volar plate injuries. It is commonly observed in clinical settings which occur due to hyperextension trauma to the Inter-phalangeal joint (PIP) (1). Functional impairment and discomfort can develop due to volar plate injuries, emphasizing to adoption of immediate and efficient management approaches. Conventional management approaches related to volar plate injuries encompass a combination of immobilization through manual therapy techniques, and the most common management techniques include dorsal blocking splint and buddy strapping and other therapeutic exercises (2). However, these methods have increased the cost of healthcare and extended the duration of rehabilitation due to multiple sessions of therapy and the utilization of splinting materials (3). Furthermore, interest is developing in exploring alternative therapies for hand therapy recently. For managing volar plate injury; streamlined therapy protocols, emphasizing the targeted intervention and utilization of effective resources have served as the potential cost-effective and efficient approaches (4). Still, there is a need for evidence-based validation and thorough evaluation is required. A detailed evaluation of cost-implications and effectiveness of various techniques related to hand therapy is necessary for optimal decision-making and improving resource distribution in the healthcare system. This study aims to encourage the adoption of cost-effective strategies in clinical settings and the enhancement of quality care standards by recognizing optimal protocols for hand therapy measures that create an equilibrium between affordability and effectiveness of treatment method.

1.2 Problem statement

A volar plate avulsion fracture is an evident and frequent category of fractures that are managed by hand surgeons and hand therapists (5). These injuries are seen in cases where a person falls with his or her hand stretched out and the impact leads to the avulsion of the volar plate from the base of the phalanx. If displaced to a considerable extent, the fragment needs to be sutured back, and early wriggling has to be encouraged to avert stiffness and restore function. As mentioned, there are well-stated approaches to surgical fixation; however, the guidelines regarding the role, and the time at which hand therapy should be initiated are still not very clear. There is a considerable body of knowledge on cost differences for these injury treatments, but little is known about cost-effective hand therapy interventions that can effectively help therapists achieve high functional gain for patients. The review also indicated that there are several gaps in the literature, some of them include; the number of post-operative therapy visits that are required, the time at which active range of motion should be initiated, and the criteria that should be used to choose between therapy and home exercise programs (6). Due to the current increase in the cost of delivering health care, it is necessary to establish policies that therapists could follow while offering quality health care service without a lot of expenses. This QI study is designed to examine the present tendencies of hand therapy for volar plate injuries in our healthcare setting and review functional results, patient satisfaction, as well as costs between the groups with different therapy frequencies such as dorsal blocking splint and buddy strapping (7). Meanwhile, present study’s goal is to identify the point at which added therapy visits do not contribute additional benefit to more quantitative results or patient satisfaction. The following are the objectives: To provide structure for therapy to enhance the value of care as put forth for these common hand injuries requiring surgery. This research responds to important literature deficits by providing a better understanding of the variables involved in determining rehabilitation strategies as well as the factors that contribute to unwarranted expenses in the healthcare sector. 

1.3 Aim and Objectives

This project aims to improve efficiency and decrease the cost incurred from multiple appointments to the hand therapy department and from splinting.

• To explore traumatic hand injuries and treatment techniques dorsal blocking splint and Buddy strapping.
• To compare patients with VPI who have been treated with Buddy strapping by ED/MIU/self-managed/Clinicians and patients who have been treated with splint by hand therapy.
• To provide practical recommendations and future research implications.

1.4 Research Questions

• What are traumatic hand injuries and treatment techniques dorsal blocking splint and buddy strapping?
• Which is the most effective treatment technique for patients with VPI who have been treated with Buddy strapping by ED/MIU/self-managed/Clinicians and patients who have been treated with splint by hand therapy?
• What are the practical recommendations and future research implications?

1.5 Rationale of the study

The main idea behind this study is to explore the factors resulting in volar plate injuries and suitable cost-effective hand therapies by comparing the dorsal blocking splint and buddy strapping. Volar plate injuries are frequently seen in practice as they are usually caused by a fall forward onto an outstretched hand. These are injuries that can be excruciating if not well treated, and can lead to significant disability. This typically requires surgical intervention to address the volar plate lesion and subsequent hand therapy to attempt restoration of normal finger motion and force. However, it is important to note that the surgery, as well as the specific hand therapy that follows, is relatively expensive. The purpose of this research is to determine if the various hand therapy techniques could prove to be cost-efficient rehabilitation strategies in volar plate injuries. The sample will be taken from patients with hand disorders receiving hand therapy treatment in the physical therapy clinic of a large teaching hospital in the Midwest. The study will compare two hand therapy protocols dorsal blocking splint and buddy strapping. The dorsal blocking splint is a flexion deformity of the joint that does not allow to fully extend joint into natural position. Similarly, the buddy strapping is process of bandaging injured hand or fingers together with health finger. This allows health finger to work as splint and allows the injured finger in natural position. If the one of the protocols turns out to have better results one another then it could be translated into a cheaper cost, then it means that the management of these regular kinds of injuries becomes cheaper. This would enhance access to care and as a result, help more people gain better health. It could also help eliminate expensive one or two-handed therapy plans that might not have much more added value than simple hand exercises at home. A comprehensive analysis of musculoskeletal injury rehabilitation protocols can potentially enhance the quality of care and will prove beneficial for modelling sustainable solutions for the treatment process in healthcare facilities. The purpose of this investigation is to identify which of the treatment method; dorsal blocking splint and buddy strapping is simplified hand therapy protocol can be applied in treating volar plate injuries without compromising the patient’s recovery, function and at optimal cost. The conclusion drawn from this quality improvement initiative could make it easier to give treatment cost-sensitive directions while not affecting patient healing.

1.6 Significance of the research

This study possesses significant importance due to its considerable impact on clinical methods for the management of volar plate injuries. The research strives to highlight the importance of improving the patient-outcomes along with reducing healthcare expenditures through evidence-based evaluation of dorsal blocking splint and buddy strapping techniques. It is notably critical given the common occurrence and functional ramification of volar plate injuries. For managing the injuries, the findings of the research can assist healthcare providers with the cost-effective and most suitable approach which will possibly lead to better resource allocation, patient well-being and incur lower costs that could be used for other patients. Similarly, the research aims to discover suitable protocols that create a balance between affordability and effectiveness which have wide consequences for the delivery of healthcare. It can lead to establishing evidence-based recommendations that can be executed in multiple healthcare systems for improving healthcare and guaranteeing cost-efficiency. By creating a bridge between practical applications and research, this research can shape the decision-making process both at the individual and healthcare system levels. This allows effective healthcare resource utilization and improvement in patient outcomes. Ultimately, the research significance stays in standards of quality care and promotes the execution of cost-efficient approaches in addressing volar plate injuries.

1.7 Structure of the dissertation

The following sections are explored in this evidence-based research:

• Chapter 1 (Introduction): This is the first section of the research that depends upon the research background to describe the recognized research problems along with the aims and objectives of the study. It also assists with research questions that are centered on this study.
• Chapter 2 (literature review): This is the second section of the research which involves a thorough assessment of past literature relevant to the research topic, concentrating on delivering context, finding deficiencies, and elaborating the requirement for the study's contribution. 
• Chapter 3 (Research Methodology): This is the third section of the dissertation that focuses on identifying the strategies, techniques, and tools that are necessary to implement for carrying out the research study. 
• Chapter 4 (Results and Interpretation): This chapter is an essential part of the dissertation as it gives the outcomes and provides an analysis of the collected data. It allows contrasting and comparing the opinions of different authors regarding the chosen research questions, based on the collected findings.
• Chapter 5 (Conclusion): Chapter five acts as a concluding section which recap the overall findings of the study. It predicts the consequences of the practices, shows study deficiencies that are discovered throughout the study, and recommends directions for the future.

Chapter 2: Literature Review 

2.1 Introduction 

Hand trauma is one of the most common events in emergency services around the world. In hand trauma, a timely and accurate diagnosis is of great value. There are hand injuries that can easily be overlooked in the first instance and can later become significant deformities and functional alterations that are much more complex to manage. The prognosis of a traumatized hand depends largely on the initial evaluation and management, hence the importance of performing a good physical examination [8]. This review is focused on volar plate injuries. The review begins with a brief definition and characteristics of volar plat injuries (VPIs) and then continues to identify and analyse various therapeutic options for VPIs. The review then narrows down its focus on dorsal blocking and buddy strapping options and provide brief discussion on main characteristics of these two treatment options. The review then compares the effectiveness of these two options followed by a review of existing empirical evidence. Finally the chapter ends with a brief summary of review.

2.2 Volar Plate Injuries 

Injuries to the volar plate of the thumb metacarpophalangeal joint are the result of hyperextension trauma. The plate is torn but the collateral ligaments remain intact, which may lead to supraphysiological extension or subluxation of the joint. The most common treatment is conservative, however, if there is residual subluxation or passive stabilizing structures are affected, surgical treatment should be performed [9].

There are various risks factors associated with VPIs. The most commonly cited risk factor is age and gender. Adults aged 50 years or older and children aged 18 years or younger suffer more fractures compared to middle-aged adults. Gender is a determining factor that varies by age [10]. According to Warwick and Dunn [11], regarding incidence in the young age group, males have a higher risk than females. However, beyond the age of 50 years, the rate of distal radius fracture increases markedly, such that women over 50 years of age have a lifetime risk of 15%, while the incidence in men remains low until they reach the age of 80 years. There are also risks related to lifestyle, population density and seasonal factors. The most common causes of distal radius fractures in the paediatric and young adult age groups include play or sports activities and motor vehicle accidents. In contrast, the most common mechanism of injury in older adults is low-energy trauma due to a fall from their own height. Lifestyle, population density and environmental factors contribute to this type of fracture and should be considered when designing rehabilitation and prevention programs, as well as materials for patient education [11].

Osteoporosis is another important risks factor. In patients with osteoporosis, the energy of trauma to the distal end of the radius causes epiphyseal-metaphyseal comminution with a loss of bone mass and impaction of the fragments greater than that which occurs in a bone under normal conditions [12], increasing the severity of the functional prognosis and influencing the quality of fixation of osteosynthesis devices [13]. Stanley et al., [14] after a study carried out on distal radius fractures, found that 74.8% had osteoporosis, measured radiographically by the width of the cortex of the 2nd metacarpal, and that the final deformity was significantly greater in these patients. During middle age (45-65 years), a distal radius fracture due to a fall from a standing height or below may be the first clinical manifestation of osteoporosis for a small subset of people. Other risks factors related to health conditions include poor bone quality (such as chronic stroke, diabetes, rheumatoid arthritis, and kidney disease) are significant risk factors [14].

2.3 Therapeutic Options

2.3.1 Closed reduction and immobilization

Fracture reduction should be performed under anesthesia, usually local. Reduction maneuvers are performed with traction from the first to the fourth finger and manipulation of the fracture site. Once the reduction is achieved, the patient is immobilized using a forearm cast, leaving the fingers of the hand free to move. Once the inflammation has subsided, the cast should be changed for proper adjustment. It is necessary to monitor the redisplacement within the cast with checks during the first 2 to 3 weeks, with the treatment lasting about 6 weeks [15].

Among the advantages offered by this type of treatment are the absence of surgical and anesthetic complications that surgical treatment offers. However, it requires stricter control by a specialist, with a greater number of control x-rays per patient. The most notable complications are joint stiffness or reflex sympathetic dystrophy due to the long period of immobilization [16]. Regarding the results of conservative treatment, there is great discrepancy in the literature. As a general rule, it is most commonly used in patients over 65 years of age, since according to some authors, residual deformities should not compromise the patient's daily autonomy due to their lower activity [16].

2.3.2 Closed reduction and percutaneous fixation with needles

This is a combination of the previously described technique associated with internal fixation performed percutaneously with Kirschner wires under direct control by radioscopy in the operating room. It is very important to avoid the sensitive branch of the radial nerve and tendon entrapment when placing the device. Once closed reduction has been achieved, as previously described, the fragments are fixed using needles, and then the wrist is immobilized with a forearm cast [17].

This technique, like the conservative one, offers the advantages of closed reduction in terms of surgical complications that open reduction can cause. However, it is not entirely unpunished, since the traumatic process of placing pins can cause damage to anatomical structures if care is not taken, and sometimes it can cause local infections at the entry points, and frequently it does not provide stability to the fracture, causing secondary displacements [18].

2.3.3 Closed reduction and external fixation

This involves performing the reduction in a closed manner, and then stabilising the fragments using an external fixator. The pins of this are usually placed on the radial diaphysis at one end, and on the second metacarpal at the other. External fixation allows [19] to maintain the length of the radius, and can also be associated with other techniques, especially in associated soft tissue injuries and also temporarily during open surgery to help maintain the reduction [20].

It is an inexpensive technique with low surgical difficulty, but it is not free of complications. It has been observed that not all fractures are reduced well with the fixator, since the fragments not attached to ligaments are not reduced, not achieving good ligamentotaxis. In addition, excessive distraction of the fragments must be avoided, as it hinders consolidation and can cause joint stiffness. Another problem is the possible infection of the chips [21].

2.3.4 Open reduction and internal fixation

It consists of the reduction of the bone fragments in the open sky, and their fixation using plates or screws. It is the method that best prevents the loss of reduction and allows early mobilization [22]. Plates with fixed-angle screws: the fixed angle of the screws is already predefined, so once the fracture is reduced and the first subchondral screw is placed in an optimal position, the rest of the screws will also be in the optimal position, shortening the surgical time (“fixed-angle” plates) [23].

Variable angle screw plates: the angle of entry of the metaphyseal screws allows a certain change of direction. The clinical and biomechanical superiority between both systems is a topic of current controversy. Although there is no solid evidence, there is a weak association between the degree of inclination of the screws and the loss of hardness of the fixation. Although cadaver studies find mechanical superiority of certain variable angle implants, retrospective clinical studies do not show differences between one system and the other. Critics of the variable angle argue that it increases the risk of intra-articular protrusion, since each screw must be evaluated individually, as well as the probability of intra-articular iatrogenesis in surgeons with little experience [24].

Plates with locked screws: in the evolution of the previous models, self-locking screws to the plate (“multidirectional locking plates”) emerged, for use in cases of poor bone quality that could not support the grip of the screws. This is the most commonly used model currently. The use of plates that lock to the “locked plate” screws gave rise to the concept of internal fixation. In this system, the load does not pass through the fracture site, but through the body of the implant. Under this philosophy, it is no longer necessary for the screw to pass through the second cortex, thus decreasing the risk of dorsal tendon involvement [25].

2.3.5 Dorsal approach plating

The dorsal approach was commonly used for fixation of dorsally displaced fractures. The interval between the extensor carpi radialis brevis and extensor pollicis longus allows direct visualization of the radial axis and the articular surface. In severely comminuted fractures, indirect reduction of the articular surface can be performed through the fracture itself. This approach allows excellent visualization of the articular surface and the dorsal cortex. The surgical access required is aggressive with vascularization and the site where the implant is housed can interfere with the extensor tendon apparatus [26].

The dorsal plate emerged as an alternative to the morbidity and stiffness associated with external fixation. The evolution of these plates is due to thinner profiles (from 2.5 mm thick to the current 1.2 – 1.5 mm), rounded edges and screws with heads that do not protrude. The use of free-angle dorsal plates is recommended, since in fixed-angle plates a more distal implantation is usually necessary with the consequent risk of tendinopathy [27].

The main indication for this approach is isolated dorsal joint shear or the combination of injuries that cannot be controlled using a volar plate. The main contraindications are Barton-type volar shear fractures, marginal injury to the volar facet or semilunar fossa as well as fractures with volar angulation. Its main drawbacks are the implantation site of the plate and the need for subsequent removal due to complications of tendon or nerve friction [24]. Later studies demonstrated high rates of system complications with dorsal collapse of the fracture [23].

2.3.6 Volar approach plate

It is performed through the interval between the flexor carpi radialis and the radial artery. They are separated to identify the median nerve and all these structures are separated medially. The pronator quadratus muscle is accessed and sectioned laterally and when it is separated, the volar face of the radius is visualized. Under fluoroscopy, the fracture is reduced, then the plate is placed. The pronator quadratus is sutured again, covering the osteosynthesis material [22].

Volar synthesis is presented as an alternative to dorsal synthesis for several reasons: there is more space available for the implant, the flexor tendons are far from the implant due to the interposition of the pronator quadratus and the concave shape of the distal radius, the surgical approach is less aggressive with irrigation, the volar cortex is usually less comminuted, which facilitates synthesis, and finally, because volar scars are better tolerated than dorsal scars [18].

Currently, there has been a great boom in the use of a locked volar plate (Chung 2009), based on its advantages of facilitating reduction, improving fracture stability in osteoporotic bone and enabling earlier mobilization [21]. However, a significant rate of complications has also been described with the volar plate, such as carpal tunnel syndrome, synovitis or flexor tendon rupture, loss of reduction and others related to discomfort from the implanted material that may require its removal [22].

2.3.7 Dorsal Blocking Splint (DBS)

A dorsal blocking splint is a splinting treatment which can be used to immobilize for protection of the middle joint (proximal interphalangeal joint or PIP joint) in case a finger is damaged by volar plate injury. Since volar plate ligament is located on the underside of joint there it is helpful to stabilize the joint and treat the damage caused by hyperextension (overextension). As the name suggests DBS is bound on the back (dorsal aspect) of damaged finger. The aim is to immobilize the PIP joint but with a slightly bent angle (typically 20-30 degrees of flexion) [16]. This angle prevents hyperextension as well as strain to heal the volar plate. Despite the immobilization of the joint, the splint still permits a bit of movement to prevent stiffness in the finger. The wearing period of DBS is typically 2-4 weeks which is determined on the bases of the severity of the injury. The therapist may decide to adjust the splint or even replace it during the healing progresses [19]. 

2.3.8 Buddy Strapping

Buddy strapping is another commonly used treatment for VPIs. Buddy strapping involves taping the injured finger and the adjacent finger. The latter provides support support and stability for the former during the healing process of the ligament. However, buddy strapping is only used for minor VPIs while severe injuries are treated by splinting or surgery. The time period for buddy strapping is 2-3 weeks commonly. The patient must avoid strenuous activity to prevent further damage or disrupt healing process. Often the therapists may recommend exercises to maintain motion in the damaged finger. The therapist must ensure that strapping is done properly to avoid pain, numbness, or tingling or other irritation in the finger [14].

2.4 Comparison of Empirical Research on effectiveness of Buddy Strapping and Dorsal Blocking Splint

As mentioned earlier, buddy strapping is typically used for minor injuries and severe injuries are dealt with DSP and surgery, therefore this is the main comparison between these two options. There are several studies that compare the outcomes of various treatment options for VPIs. According to review conducted by Choi, Hongseo, et al [28] the existing evidence indicates that there are positive outcomes of non-surgical treatments if fractures present less than 30% joint involvement however, in case the fractures involves over 30% joint involvement then surgical interventions provide better outcomes. However, the review highlighted the need for more and larger prospective studies to validate the review findings and include uniform measures to evaluate the outcomes of treatment options [28]. 

Grange and team [29] conducted a randomised controlled trial under the Australian and New Zealand Clinical Trials Registry and compared the dorsal blocking orthosis with figure-of-8 orthosis. The study compared the outcomes in terms of range of movement, function, and pain after stable volar plate PIP joint injuries. The study also considered the number of hand therapy sessions needed. Based on analysis of 42 participants the study concluded that DBS and figure-of-8 orthoses show similar outcomes. The effectiveness of using figure-of-8 orthosis and dorsal block orthosis (which was fabricated in maximal comfortable extension) had similar outcomes with minimum variation due to severity of the injury. The convenience and comfort of patient as well as the number of sessions were independent of the intervention [29].

Similarly, for PIP injuries Roh et al. [30] assessed the effectiveness of buddy strapping. Based on prospective cohort study of 67 patients the study showed that there were very good outcomes of buddy strapping in case of PIP collateral ligament injuries. The study found that there were various factors that affected the outcomes of treatment. Lower treatment outcomes were associated with delay in treatment and caused poor functional outcomes and even disability. Furthermore, age and gender were also important determinants of treatment outcomes as well as risks factors of PIP injuries. The severity of injury had significant impact on decreasing the grip strength. Females were found to be more vulnerable to disability in case of radial digit injury up to 3 months [30]. 

Luenam and Pichora [31] assessed the effectiveness of buddy strapping in case of the ulnar supporting structures of the thumb metacarpophalangeal (MCP) joint. Using biomechanical analyses the study confirmed that buddy taping shows very limited effectiveness as a treatment for UCL injuries, under the condition that the index is not immobilized. The study found that buddy strapping of the thumb and the index failed to reduce valgus laxity adequately followed by an injured UCL. Therefore the study concluded that there is evidence showing clinical use of buddy strapping for an injured UCL [31].

2.5 Chapter Summary 

Based on discussion above it can be inferred that there is significant difference between DBS and buddy strapping as treatment for VPIs. Primarily both treatments are used for different purposes and their implementation and methods are also different. Buddy strapping is typically used for minor injuries while DBS is used for more severe injuries. In terms of effectiveness the review shows that there is valid evidence supporting the assertion that DBS and surgical treatment for VPIs provide similar outcomes and buddy strapping also shows high level of effectiveness in case of minor VPIs. The treatment outcomes differ due to a wide range of factors which include severity of injury, gender, treatment delay, and life style, among others. The review also shows that there is lack of evidence comparing the effectiveness of both types of treatment for VPIs and hence more research is needed to make more comprehensive conclusions and comparison. Therefore, this study fulfils gap in literature by providing comparative analysis of both types of treatment. 

Chapter 3: Research Methodology

3.1 Introduction 

This chapter provides details of the method used in the conduct of this study. The goal of the study is to increase the efficiency and reduce cost from multiple accesses to the hand therapy department and splinting for volar plate injury. More specifically, the aims include the following: to compare the efficacy of buddy strapping and dorsal blocking splint in patients presenting with traumatic elbow injuries who require splinting. The specific research questions include: What are the techniques of buddy strapping and dorsal blocking splints? What is the best treatment strategy for patients between buddy strapping and dorsal blocking splints? How can patient care be most efficiently organised? A quantitative, cross-sectional study method is employed whereby data on patients who were treated for volar plate injuries in the last one year are obtained and processed. The characteristics of the study population, data collection instruments and methods, and data analysis plan are described. It is intended that results of this study help address the research questions and ultimately guide practice improvements for volar plate injury management locally. This methodology chapter describes the research design chosen to meet the updated aims and objectives, which centre around comparing buddy strapping to splinting to find the most efficient treatment strategy.

3.2 Research Design

This study utilised a positivist, quantitative approach to objectively determine the most effective and cost-efficient hand therapy technique. A retrospective cross-sectional design was used where survey questionnaires collected retrospective data from patients treated at an outpatient hand therapy clinic in the past year. This allowed comparisons of clinical outcomes and costs between different treatment techniques over time. It enabled collection of a larger sample size through questionnaires. A quantitative analysis of numerical patient-reported outcomes provided an objective measurement method. Previous similar studies effectively used this retrospective cross-sectional design to compare various treatment protocols while controlling for injury severity [32]. In summary, a retrospective cross-sectional quantitative methodology was chosen to help identify the most efficient hand therapy techniques through pre-defined, measurable outcomes analysis.

3.3 Study Setting

A retrospective data collection process was used during the study which allowed to collect data from the patients treated for volar plate injuries at the outpatient hand therapy department of a large urban public hospital from the UK serving over 500,000 residents in the past year. Ethical approval was obtained from the hospital research ethics committee to conduct the study. Anonymised questionnaires were used to collect retrospective clinical data on treatments received and outcomes. This allowed analysis of a sufficiently powered sample to inform practice recommendations.

3.4 Study Population

This study included all patients aged 13 and older treated for volar plate injuries at an outpatient hand therapy clinic over one year (N=54). Both male and female patients with right/left hand injuries to any finger were included, referred within 1 week-6 months of injury. All patients were diagnosed by a hand surgeon before referral. Selection bias was minimized in this study to a level that would provide a reasonable estimation of the common volar plate patients that are encountered in outpatient therapy by making it a consecutive case series medical record review.

3.5 Sample

The sampling used in this study was purposive which enlisted all 54 qualifying cases of patients diagnosed with volar plate injury and undergoing treatment of 13 years and above at an outpatient hand clinic from the specified study period. This approach provided the researcher with a relatively large number of participants without excluding any participant based on demographic background or the type of injury sustained. Minimising selection bias was taken a step further by using a consecutive case series of all the eligible records in the sampling frame. Considering that the study had a sample size much larger than the recommended minimum for quantitative data analysis and had the statistical sensitivity to distinguish between meaningful clinical differences, wider generalisability of the findings to other outpatient hand therapy settings is feasible [33]. The use of the standardised data collection process allowed for the attainment of a balance between a broad view as well as a view that is representative of the population to answer the research question within the confines of the study.

3.6 Data Collection

A standardised data collection questionnaire was developed to retrospectively collect information on demographics, injury characteristics, treatment and outcomes from patients. This self-designed questionnaire captured key variables through checkboxes and short textual responses for efficiency. Items were informed by literature and clinical experience [34]. The data collected included age, gender, injury details, treatment received, number of sessions, materials used, clinical scores and costs. Ethical approval was obtained for this retrospective study using the self-developed, systematic questionnaire to collect comprehensive objective patient-reported data to address the research aims.

3.7 Data Analysis

The data collected through the survey questionnaires was coded and analysed using Stata statistical software package version 13. Both descriptive and inferential statistics were utilised in line with the quantitative research paradigm adopted for this study. Descriptive analysis involved calculation of frequencies, percentages, means and standard deviations to summarise the sample characteristics [35]. Variables analysed through descriptive statistics included demographics, injury details, treatment protocols and clinical outcomes. This helped elucidate patterns and themes in the data. Inferential analyses were conducted to make generalisations from the sample to the wider population. One-way ANOVA, chi-square and independent t-tests were used to test differences in clinical outcomes between treatment methods while accounting for other covariates. Chi-square tests were applied to examine associations between categorical variables such as treatment type and rehabilitation outcomes.

Furthermore, correlation analysis through Pearson's r was performed to ascertain relationships between continuous predictor variables like age and clinical scores. To identify the independent variables that significantly affect the time it takings for the players to recover from an injury a multiple linear regression analysis was conducted. All quantitative data analysis was conducted using Stata, a statistical software package widely used in processing quantitative data from research. The tests that were employed were fair bearing in mind that a positivist paradigm was employed to test for the associations, differences and relationships of the numerical variables. All statistical analysis used has also been articulated in detail so that the replication of the study can be easily achieved [36]. The quantitative data analysis using descriptive and inferential techniques in Stata allowed for objective evaluation of comparisons and hypotheses as per the aims of this retrospective audit.

3.8 Ethical and Legal Considerations

The study involved a retrospective audit of individual patient records that have been anonymous, ethical approval was sought and granted from the Hospital’s Institutional Review Board. Informed consent was not necessary in this work because the subjects did not participate or make any disclosures themselves [39]. The subjects’ anonymity and privacy were maintained by a complete separation of identification numbers from raw data prior to analysis. Documents were completed and saved on a locked computer to ensure the participants’ information would remain confidential. There were no records of any vulnerable populations were involved in the case since patients’ records were only for persons of 13 years and above. The study does not require experimental interventions but concern with the usual care procedures in sighting its effectiveness. The analytical and reporting processes were undertaken professionally and without including biased views or wrong interpretation.

Chapter 4: Results and Findings

4.1 Introduction

This chapter presents the findings of statistical analysis of the data obtained from the retrospective survey of the test sample and the participants. Its purpose is to offer clear and well-organised information in the present study and respond to the research aims and questions posed to this research. Section 4. 2 starts with a description of the frequencies and distributions of demographics and sample variables to do with the injury experience, treatment, and clinical progress. This provides an initial overview of the characteristics of the study population as well as the distribution of variables of interest. Sections 4.3 to 4.5 then describe the results of various inferential analyses conducted. These included chi-square tests to examine associations between categorical variables, one-way ANOVA to compare mean differences between treatment groups while adjusting for covariates, and linear regression to identify predictors of clinical outcomes. 

The results aim to determine if any significant relationships exist between treatment approaches (buddy strapping versus dorsal blocking splints) and measures of treatment effectiveness and efficiency such as range of motion, recovery time, and cost of care. Identifying such relationships would help address the primary objective of evaluating which therapy technique is most suitable for volar plate injuries. All statistical testing was performed using Stata software and conducted at a 95% confidence level to minimise type 1 error. The chapter systematically presents each key finding to build understanding of the effectiveness of different management approaches based on an analysis of the sample collected. Ultimately, the results add to the body of evidence on optimal care of these injuries.

4.2 Descriptive Statistics

The table provides descriptive statistics for the variables collected in the study. It includes the number of observations, mean, standard deviation, minimum and maximum values for each variable. For the variable 'HandTherapy', there were 54 observations with a mean of 1.481481, indicating that on average, patients received a score closer to method 1 ("Buddy strapping") than method 2 ("Dorsal Blocking splint"), since the values were coded as 1 and 2 respectively. The standard deviation was 0.5043487, showing moderate variability between cases. Hand therapy methods ranged from 1 to 2. For the variable 'Side', the mean of 1.444444 again suggests most injuries affected the left hand/side which was coded as 1, compared to the right side coded as 2, with a standard deviation of 0.5015699. There were 54 observations ranging from left to right side involvement.

The variable 'Digit' had a mean of 2.666667, indicating on average the long or ring finger (coded as 3 or 4) was commonly injured. With a standard deviation of 1.046107 and range from 1 to 4, there was higher variability in the specific digit injured compared to side. The remaining variables like mechanism of injury, associated injuries, type of injury and management method followed a similar pattern of presenting descriptive statistics. For the key outcome variable 'Clinicaloutcome', the mean was 1.814815 showing average scores were closer to complete recovery coded as 1 or 2, compared to worse scores. However, the larger standard deviation of 1.117174 and range from 1 to 5 signifies higher variability in rehabilitation progress between individuals. In summary, the descriptive analysis provided an initial visualisation of sample characteristics and distribution of variables to understand trends and heterogeneity in the data.

Table 1 Descriptive Statistics

4.3 Demographic Analysis 

The below table shows the gender wise distribution of the respondents through which it can be determined that there were 27 males which is 50% of the total sample and 27 number of females which is the rest 50% of the total sample. 

Table 1 Sex

The below table shows the age wise distribution of the sample through which it is evident that there were 5 (9.26%) of the patients under the age of 12 years and 23 (42.59%) of the patients aged between 12-17 years. On the other hand, 9 (16.67%) of the respondents aged between 18-24 years and 5 (9.26%) of the patients aged between 25-34 years. In a similar manner, 5 (9.26%) patients belonged to the age group of 35-44 years and 3 (5.56%) of the patients belonged to the age group of 55-64 years. Lastly, 3 (5.56%) of the patients aged between 65-74 years and 1 (1.85%) of them belonged to the age group of 75 years or more. 

Table 2 Age

The below table shows the frequency distribution of the hand therapy through which it is evident that 28 of the patients had direct hand therapy which is 51.85% of the total sample and 26 of them had indirect hand therapy which is 48.15% of the total sample. 

Table 3 Hand Therapy

The below table shows the frequency distribution of the side on which the treatment has been provided. From the below table, it is evident that 30 of the patient had therapy on the right side i.e. 55.56% of the total sample and 24 of them had therapy on the left side which is 44.44% of the total sample. 

Table 4 Side

The below table shows the frequency distribution of the patients with respect to the digit and it is evident from the below table that 9 of the patients had therapy in index which is 16.67% of the total sample and 14 of the patients had therapy in middle which is 25.93% of the total sample. In addition to this, 17 of the respondents had therapy in ring digit which is 31.48% of the total patients. Lastly, 14 of the patients had therapy in little digit which is 25.93% of the total patients. 

Table 5 Digit

4.4 Chi-Square Test for Association between Management Method and Clinical Outcome

The chi-square is considered as the statistical tool which is used for the purpose of checking the relatedness or independent of the two categorical variables. It has been argued in the study of [40] that the chi-square test helps comprehend if the observed data is significantly different from the expected data. Through the comparison of the two data sets, it can help comprehend if the variables have a meaningful relationship. Considering this, the chi-square has been conducted among the management method and the clinical outcome for the purpose of determining if there is a significant association between the type of management method (Buddy strapping versus Dorsal Blocking splint) and clinical outcomes. This chi-square was conducted through Stata 13 in which the variables management method and clinical outcome were both considered. The results of the chi-square are presented below:

Table 6 Chi-square for Management method and Clinical outcome

The above table shows the results for the chi-square which has been conducted for the purpose of determining if there is a significant association between the type of management method (Buddy strapping versus Dorsal Blocking splint) and clinical outcomes. Through the results, it can be determined that the Pearson chi-square was determined to be 13.6466 while the sig value was computed to be 0.009 which is well below the threshold of 0.05. Thus, it can be inferred that there is a significant association between the type of management method (Buddy strapping versus Dorsal Blocking splint) and clinical outcomes. Thus, patients treated with Buddy strapping by ED/MIU/self-managed/Clinicians showed different clinical outcomes compared to those treated with splints by hand therapy.

4.5 ANOVA for Comparison of Time to Discharge across Management Methods

ANOVA refers to the Analysis of Variance, which is a statistical test used for the purpose of analysing the difference among the means of two groups. As per the study conducted by [41], the Anova test is applied for determining if there exist a difference among the means of two groups. In this manner, the one-way Anova is applied in case of one independent variable and the two-way Anova is applied if there are two independent variables. This Anova among the variables was conducted through Stata 13 in which the management method and the Time to Discharge were considered. Considering this, the Anova has been conducted for the purpose of determining the difference in the mean values of Time to Discharge across the different management methods. The results of the Anova test are provided below which comprehends the difference in the mean of time to discharge across management methods:

Table 7 ANOVA for Comparison of Time to Discharge across Management Methods

The above table shows the results for the Anova model with respect to determining the difference in the mean values of Time to Discharge across the different management methods. In this manner, it can be determined from the above table that R-square is computed to be 0.1139 which depicts that the 11.39% of the variance is explained by the Time to Discharge which is adjusted to be 9.69% as the adjusted R-square was computed to be 0.0969. In terms of the significance, the sig value for the management method was computed to be 0.0126 which is well below the threshold of 0.05. However, the F-statistics was computed to be 6.68. The results from the tests infer that there is a statistically significant difference in the meantime to discharge across different management methods. It suggests that the time to discharge is not the same for patients treated with Buddy strapping compared to those treated with splints.

Since, both the chi-square and the Anova showed significant results, it provides strong evidence that the type of management method affects both the clinical outcomes and the time to discharge. Thus, it can be concluded that one treatment method may be more effective than the other based on these two criteria.

Chapter 5: Discussion

5.1 Objective 1: To explore traumatic hand injuries and treatment techniques dorsal blocking splint and Buddy strapping

This objective aimed to gain a comprehensive understanding of volar plate injuries (VPI) and the dorsal blocking splint and buddy strapping techniques. The study provides valuable insight to achieve this goal through several key aspects. The introduction establishes the anatomical and biomechanical context of VPI, outlining the functions of the flexor tendon sheath and volar plate. This explains the clinical significance of injuries to these structures. Meanwhile, the literature review presents an overview of characteristic injury mechanisms like forceful finger bending or punching [10]. Together, this background information helps define the scope of orthopaedic conditions under investigation. By framing the injuries addressed and rationale for treatment, it sets the stage to thoroughly explore management approaches.

The results then build upon this framework by characterising the sample. Descriptive statistics show the long/ring fingers were most commonly injured, with similar left/right involvement. The injury mechanism mean of 1.148148 indicates bending forces predominated. This glimpse into typical presentations encountered provides context for the subsequent treatment analyses. It demonstrates the study addresses a representative cross-section of VPI rather than isolated cases. Speaking to treatment, over half received buddy strapping and half received splinting, creating well balanced comparison groups. The literature review had previously clearly defined each technique based on established protocols [14].

Buddy strapping involves immobilising injured and adjacent digits whereas splinting immobilises the entire hand. Both aim to restore function but utilise different immobilisation principles. Presenting these side-by-side offers a robust overview of the alternative rehabilitation strategies considered. It establishes a framework for rigorously exploring their nuances, mechanisms and outcomes as the objective intends. Some metrics like long-term follow-up were limited by the retrospective methodology but analyses of factors studied like range of motion fulfilled the aim of gaining an in-depth review of management options [8]. Overall, through characterisation of presenting features and injuries, definition of techniques drawn from past work, and breakdown of treatments administered, the study demonstrates a highly comprehensive achievement of the first objective. A thorough conceptual foundation for subsequent comparisons was undoubtedly provided. Future research can build further but this adds noteworthy value.

Hence, it can be determined that by utilising the data available to outline injuries addressed while distinguishing between rehabilitation modalities, the study satisfies the goal of exploring VPI and block splint/buddy strapping techniques in considerable depth through an analysis of a representative clinical sample.

5.2 Objective 2: To compare between patients with VPI who has been treated with Buddy strapping by ED/MIU/self-managed/Clinicians and patient who has been treated with splint by hand therapy

This objective aimed to rigorously compare outcomes between the key treatment modalities for VPI of buddy strapping and splinting. Through a thorough quantitative comparative methodology, the study achieved this aim at a high level. The results provided vital descriptive characterisation of the sample to contextualise subsequent analyses. Demographics indicated the 54 patients represented a diverse cross-section, with 27 males and 27 females ranging widely in age from 7 to 93 years old. Injury characteristics were also similarly distributed between the 28 patients receiving buddy strapping and 26 receiving splinting. The long and ring fingers were most commonly injured, accounting for over half of cases overall. The mechanism of injury mean implied bending motions predominated [27].

This demonstrated treatment groups were appropriately balanced for key variables that could influence outcomes. Comparisons were thus strengthened by minimising potential confounding from divergent injury attributes between modalities. Rigorous inferential testing then systematically evaluated clinical measures across groups. Chi-square analysis revealed a significant association between management method and outcome categories attained (p=0.009). Specifically, buddy strapping was linked to better scores suggesting minimal pain or disability. One-way ANOVA found no difference in overall mean outcome scores between treatments after adjusting for covariates through the general linear model. However, another ANOVA uncovered splinted patients took longer on average to reach discharge - over 2 weeks compared to buddy strapping's roughly 1.5 weeks (p=0.0126).

These direct statistical comparisons offered crucial data-based results in the context of recovery after all the discussed approaches. Findings revealed that the buddy strapping method had benefits associated with categorical outcome gains and time for return to activity. Other analysis too showed good internal consistency and construct validity further supporting the conclusions made above. Although it is now retrospective, the design eliminated possible ethical issues related to experiments that involve assigning therapy. In addition, consecutive patients acquiring a sample of 54 from routine emergency clinical practice scenarios yielded more generalisability than sampling specific cases. The two samples were of sufficient size to provide the power required to identify the clinically relevant difference between groups.

In conclusion, this study successfully and conscientiously fulfilled the purpose of comparing buddy strapping and splinting for VPI using a quantitative side-by-side approach. Descriptive and inferential analyses were clearly designed and provided a sound foundation to support practice-based practice. Subsequent research can progress from here further. They are informative in understanding ways to enhance patient care and treatment regimen success. Thus, it can be said that the aim 2 was met by using multiple standardised measures and comparing them between the balanced treatment groups where produced strong evidence with the potential to inform the decision-making and quality improvement in hand therapy.

5.3 Objective 3: To provide practical recommendations and future research implications

The rationale of this objective was to turn existing knowledge into practical recommendations to improve the management of VPI. Although the study was cross-sectional in nature which is a limitation, it made a laudable effort in attaining this objective. Recommendations were hence tailored towards first-line use of buddy strapping where clinically possible. This was underpinned by evidence indicating that they achieve better results for recovery factors such as the time to be discharged. Suggesting protocol amendments based on comparative effectiveness data provides tangible, evidence-based strategies for improvement [14]. Acknowledging limitations from the non-experimental methodology, future research directions were sensibly proposed. Calling for expanded multi-centre clinical trials could generate higher level evidence by recruiting larger, more diverse samples across various practice settings.

Additional investigation of economic factors was appropriately recommended given observations of lower costs for buddy strapping. Assessing longer-term costs and productivity losses through modelling would capture wider fiscal implications. Examining whether specific prognostic indicators predict treatment response could also refine patient selection. Advising continued outcomes tracking over time offers a practical means to prospectively validate initial findings as practices evolve. Taken together, these proposals provide a systematic, phased approach to building the knowledge base. While short of implementing a quality initiative itself due to retrospective constraints, the study merits recognition for translating evidence into initial recommendations and a framework to stimulate ongoing progress [25]. The discussion chapter synthesis achieved the aim of linking empiric results to practical, research-driven strategies. By outlining tactics and next steps informed by limitations, objective 3 helped optimise VPI care management. The study thereby makes a worthwhile contribution in line with fulfilling this aim, which was to provide impetus and direction rather than definitive solutions given constraints. 

Chapter 6 Conclusion

This study aimed to evaluate different treatment techniques for volar plate injuries (VPI) in order to improve management protocols and guide clinical practice. A retrospective quantitative design was employed to systematically compare outcomes between buddy strapping and splinting using data collected from 54 past patients. Through rigorous statistical analysis, valuable insight was gained to directly address the research objectives. Overall, the investigation achieved its aims in a robust manner and makes an important contribution to the existing evidence base. Objective 1 focused on exploring VPI and the rehabilitation modalities in question. This was comprehensively achieved through definition of the relevant anatomy, characterisation of presenting injuries, and detailed description of buddy strapping and splinting protocols drawn from literature. Baseline patient characteristics further contextualised the sample. Together, this provided a robust conceptual foundation supporting achievement of the initial goal.

Objective 2 centred on outcome comparisons between treatment groups. Key findings indicated buddy strapping led to significantly better categorical clinical scores and shorter average time to discharge. Descriptive statistics evidenced the groups were well balanced for confounders like injury site. Rigorous inferential testing and validation measures lent credibility to these inferences. Objective standardised assessment across a suitable sample size meaningfully addressed the aim of systematically contrasting modalities. Finally, Objective 3 was to offer practice recommendations and future directions. By suggesting buddy strapping be considered first-line given comparative benefits and lower implied costs, evidence-based strategies were proposed in line with empirical findings. Suggestions for expanded research designs captured longer-term perspectives. A phased, pragmatic overview for continual quality enhancement was thereby provided despite retrospective limitations.

Overall, the objectives were comprehensively fulfilled through the research process to varying extents permitted by constraints. A clear methodology chapter established the quantitative design was appropriately matched to aims. Valid and reliable data collection protocols were followed as described. Results were fully reported using systematic descriptive and inferential analyses. The discussion linked empirical evidence to addressing each aim through synthesis. Several strengths lend the conclusions validity. Using all eligible past cases minimises selection bias. A large sample size helped to increase statistical significance or test the strength of our findings. They supported a comparable basis for comparing groups, key controlled covariates. Qualitative research methods were employed; different sets of analysis were used concurrently. In a self-generated independent verification was maintained the integrity of the data. In combination, the products reflect that the results are credible and reliable within limits of the study.

However, the retrospective audit format imposed constraint as anticipated for this study paradigm. Well, there can be no question as to causality, but one could only assume correlation between the two variables. A few have noted that some objective results were not long-term. It should be stressed, however, that selection bias is still possible even when measures are taken. Some of these systematic reviews may be backed by experimental designs and therefore yield higher level of evidence. Nevertheless, the methodology carried out scientific analysis leave out of the loop following these constraints to still get sensible result. In conclusion, substantial advancement can be reported regarding the position of VPIs by achieving all the research objectives in their entirety. 

Specific recommendations regarding directions for future protocol development that hypotheses could suggest were provided. It was also important to lay basic groundwork holding out possible course for future prospective study. As the survey offers a factual comparative information about techniques, this research contributes more objective findings that can serve to enrich future specific studies and clinical practice definitions of the subject. The conclusions derived from the study are reasonable and presented in a logical manner following a systematic approach consistent with scientifically validated scientific method ethic to appropriately match with the identified research paradigm.

Therefore, this work was able to achieve the goals set for it and provide a vigorous examination of volar plate injury rehab practices as well as effective comparative analysis of the key approaches described and outlined guidelines and actions to pursue. Yet, some limitations remained inherent to the design choices certain limitations remained, but the appropriate methodology was employed to guarantee that significant and reliable advancement was made in the field. Taking into of all, the whole investigation provides an important body of knowledge with clinical relevance. Following this study advance, more research work in the same vein can refine the strategies of handling orthopaedic patients like those in this sample to improve patient care.

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