Introduction The reflective framework chosen for this case study is that of Peters (1991). This framework has been used and favourable evaluated within education (Bell and Gillett, 1996). Peters’ (1991) reflective framework incorporates a guideline called DATA comprising four steps;
The first step is the description of an aspect of practice the clinician wants to change. Identification would be made of the context and the reason the clinician wants to change the practice and their feelings about this. Analysis involves identification of the factors that lead to and the assumptions that support the present approach. This includes analysis of beliefs, rules and motives supporting the present approach (Imel, 1992). Theorizing is the next step which looks at the theories for developing a new approach building on the theories that were identified that were supporting the present approach. The final step is the action putting the new theories (if appropriate) into practice to ensure that such cases continue to be managed appropriately in the future. “Success of this process would occur only through additional thought and reflection” (Murray, 2006).
At 11 am a 64 year old lady presented to the Accident and Emergency Department with a painful right wrist following a fall. We shall call her Betty but, in order to protect confidentiality, that was not her real name. She had been brought to the department by car by her husband.
Betty was seen by the triage nurse and subsequent upon waiting her turn was allocated a cubicle. I saw her at 11.20 hours.
An understanding of the pathophysiology of fracture is important if important aspects of the patient’s history are not to be missed. Firstly taking an adequate history of the accident, including details of the mechanism of the fall, will help the clinician to decide whether the amount of force applied to the bone would be of the degree that would be expected to cause that particular fracture. Secondly there may be underling osteoporosis leading to fracture with minimal trauma. There may be factors in the history suggestive of osteoporosis e.g. use of systemic steroids (Angeli, 2006) or early menopause without subsequent hormone replacement therapy. A fracture which occurs after only minimal trauma and from a standing height or less, the degree of trauma being that which would not normally be expected to fracture healthy bone, may be what is known as a fragility fracture. This occurs where a bone is weakened by a pathological process , (Majid and Kingsnorth, 1998) such as osteoporosis. In distinction a pathological fracture occurs because of metastatic bone disease. Thirdly not just the mechanism of the fall but the reason for the fall needs to be considered. Betty had slipped on some ice when walking outside to her car. In the absence of such a clear history other factors in the history should be considered; for instance “funny turns,” visual problems, cerebrovascular accidents, or non accidental injury. It is important to directly enquire about that last aspect.
On inspection Betty’s right wrist was swollen. The skin was intact. There was some distortion of the normal contour of the arm typical of a “dinner folk” deformity. The distal part of the radius was angulated dorsally, the wrist supinated and the hand deviated towards the thumb. On palpation the distal radius was markedly tender. There was no crepitus. Betty was unable to use her right arm at all. The radial and ulnar pulses were readily palpable and there was good capillary refill in the hand. Sensation in the radial, ulnar and median nerve dermatomes was normal as were finger and thumb movements. The preliminary diagnosis of Colles fracture was made with some degree of confidence since the patient was a 64 year old female who had fallen on an outstretched and had classic examination findings of such a common injury.