Fracture Management At the RAH most fractures are followed up at the daily orthopaedics fracture clinic. A similar system exists at IRH. There are daily fracture clinics both at RAH and IRH. From RAH & IRH refer emergency cases to the on-call orthopaedic FY2/Reg Fracture Policy Fractures can be divided into four types 1. Fractures requiring no specialist treatment or follow up

Can be discharged from ED but must be given appropriate advice re prognosis and GP letter must be completed. At RAH these include 5th MC, 5th MT, lateral malleolus, paediatric clavicle and radial head fractures. Specific discharge leaflets exist for these cases

2. Fractures requiring symptomatic treatment e.g. POP cast. These patients must be

followed up at fracture clinic. If followed up by ortho then they are seen the following day at the fracture clinic.

3. Fractures for whom advice is required as to whether or not active treatment is

necessary or not (surgical or MUA). Discuss with senior then refer to orthopaedic on-call

4. Those not requiring active treatment but who for any reason outpatient

management is unsuitable e.g. greater trochanter or minor pelvic fractures in the elderly rendering them immobile. Refer to orthopaedics

For all those not being admitted GP letter must be sent The specific treatment e.g. type of cast and position of immobilisation must be prescribed in the ED card Appropriate advice re rest, elevation and mobilisation of adjacent joints must be given to patient or relative Those placed in POP or backslab will be given an appointment for POP check/# clinic the following day.

All Fractures Assess distal circulation and sensation and record in notes X-Rays 1. Two views True AP and lateral 2. Two joints Above and below fracture 3. Two sides if in doubt in children 4. Special views are dealt with under specific fractures Compound fractures 1. Distal phalanges of fingers

Thorough debridement under ring block Oral Flucloxacillin (only rarely required as no substitute for adequate wound toilet/care) Ensure tetanus status ED returns wound review

2. Distal phalanges of toes as above

3. All Others Betadine soaked pad & refer orthopaedics

Overview of fracture management This is a brief description of management of the commoner fractures seen in the Emergency Department. If in doubt discuss with Consultant/middle grade staff. Also refer to textbooks in the department. Adult Fractures

UPPER LIMB Sterno-Clavicular Joint Anterior Dislocation Broad arm sling or collar and cuff sling . Fracture clinic Posterior Dislocation Refer orthopaedic Clavicle #

Broad arm sling or collar and cuff sling and follow up in fracture clinic Acromio-Clavicular Joint Grade I no displacement Grade II subluxation Grade III dislocation with tearing of AC and coracoclavicular ligaments ? Grade IIImay need weight bearing & non-weight bearing views Grades I & II Broad arm sling or collar and cuff sling . Analgesia. Advice on mobilisation. Dispense with sling after 2-3 days. Discharge to GP Grade III Refer to fracture clinic Scapular Fractures Relatively uncommon, but, if present, may indicate significant trauma so look closely for associated injury. Treat in broad arm sling. Ortho fracture clinic follow up

SHOULDER/HUMERUS Dislocation of Gleno-humeral Joint a. anterior dislocation

test and record axillary nerve function. X-ray pre & post reduction. Reduce in A&E. (if unsuccessful, refer to orthopaedic ) Blue polysling, axillary pad. Fracture clinic follow up.

b. posterior dislocation clinical diagnosis arm held fixed in internal rotation. Unable to externally rotate arm AP x-ray may look normal. Be aware of light bulb sign. Discuss with senior/orthopaedics. May require GA for reduction.

Fracture-dislocations (associated fracture) Greater tuberosity fracture without displacement

Reduce joint and check x-ray, Body bandage, collar & cuff, axillary pad. Fracture clinic follow up.

Greater tuberosity fracture with displacement > 1cm Refer orthopaedics Fracture of neck of humerus Refer orthopaedics Fracture Head/Neck of Humerus Two part fractures Humeral neck and undisplaced greater tuberosity fracture Body bandage, collar & cuff, axillary pad or Blue Polysling Fracture clinic follow up Displaced greater tuberosity > 1cm Refer orthopaedics Three or more part fractures Refer orthopaedics Humeral Shaft Test and record radial nerve function Humeral brace Refer orthopaedic

ELBOW Dislocated Elbow Check distal neurovascular status Reduce-longitudinal traction with slight flexion of elbow if needed. Check x-ray. Record reduction, medial epicondyle position, radial head/neck #, coronoid # Assess and record medial nerve stability Long arm back slab Discuss with orthopaedics. May need admission for elevation Fracture-Dislocation Elbow Refer orthopaedics Distal Humerus Classification Supracondylar Intra-articular Transcondylar/intercondylar Refer to orthopaedics Olecranon Undisplaced -long arm backslab Any displacement-refer to orthopaedics Radial Head Classification Mason Type 1 undisplaced Type 2 marginal with displacement Type 3 comminuted involving the whole of head Type 4 associated with dislocation of elbow. Minor radial head involving less than 1/3rd of the articular surface can be discharged with a collar & cuff and advice leaflet (RAH) no follow up required. At IRH refer # clinic

All other radial head fractures refer to orthopaedic fracture clinic. If complicated refer to on-call orthopaedics Radial Neck Undisplaced padded crepe and broad arm sling Fracture clinic Displaced > 150 refer orthopaedics Post traumatic effusion/No obvious fracture Treat symptomatically with collar & cuff sling and discharge with radial head # advice sheet.

FOREARM FRACTURES Ring structure, so will disrupt in two places in indirect damage. Isolated fracture only with direct below. Fracture dislocations Galeazzi Fractured radius with dislocation of radio-ulnar joint. Refer to orthopaedics Monteggia Fractured ulna with dislocation of radial head. Refer to orthopaedics Fracture of Radius and Ulna Refer to orthopaedics Isolated ulna shaft ‘nightstick fracture’

WRIST

Fracture Dislocation Transcaphoid/perilunate dislocation Obtain true lateral x-ray High energy injury Think if swollen painful wrist and apparently ‘normal x-ray’ Refer to orthopaedics Colles Fracture Fracture distal radius with dorsal displacement of distal fragment. Refer to orthopaedics Smith’s Fracture (volar displacement) and Barton’s Fracture (volar intraarticular#) Refer to orthopaedics Scaphoid Definite Scaphoid Fracture Scaphoid cast Fracture clinic follow up Clinical Scaphoid Typical history of fall on outstretched hand ‘FOOSH’ Scaphoid is located in anatomical snuffbox at base of thumb between tendons of extensor pollicus longus and abductor pollicus longus/extensor pollicus brevis. Always examine for and document presence/absence of ASB tenderness on wrist examination. Consider if history and 1. tender on pressure over anatomical snuff box 2. swelling over anatomical snuff box 3. pain on axial pressure of thumb 4. tenderness over dorsal and palmer aspect of scaphoid. Ask for specific ‘scaphoid views’. If no fracture then treat as ‘clinical scaphoid’ Place in scaphoid crepe or Futuro with thumb extension and refer to fracture clinic in 2 weeks time. There is no evidence to support immobilization of clinical scaphoids in casts until check x-ray at 10-14 days.

HAND

Only immobilise if absolutely necessary

If immobilising hand, use volar slab in position of function or use padded crepe Instruct on mobilisation SOFT TISSUE INJURY Ulnar collateral ligament of 1st MCP joint Clinical diagnosis of rupture. x-ray to exclude fracture Refer to orthopaedics on call for obvious laxity – operative repair always needed. Consider reviewing other patients at next STC who are too sore to assess laxity , tender and swollen over UCL & who have no # on initial xray. Closed Mallet Injury Mallet splint ED clinic in 2 weeks for wound check Advise about use of splint. Give advice card Patient will wear splint for at least 6 Weeks. Traumatic Boutonniere Splint with PIP joint extended Refer to fracture clinic Ruptured Tendons Open & Closed. Refer to orthopaedics Limited hand surgery at the RAH. These patients may require referral to the Plastic surgeons at GRI WOUNDS Any doubt, Discuss with Senior Definite tendon division or digital nerve injury, Refer to orthopaedics INFECTION Suspected flexor sheath infection or deep palmar space infection Refer to orthopaedics Paronychia Drain under local anaesthetic. If pus tracks under the nail-remove it. Most can be followed up at GP If pus drained then usually do not require antibiotics Cellulitis Oral Flucloxacillin Review at 24-48 hours. If no improvement. Admit under medicine for IV antibiotics (if hand then refer ortho) High Pressure Injection Injury

Refer to orthopaedics Human Bites See under ‘bites’ guidelines DISLOCATION Metacarpo-phalangeal Joint Refer to orthopaedics Interphalangeal Joint X-ray prior to reduction Reduce by traction (under ring block) Check x-ray Assess stability to hyperextension & lateral stability Neighbour strapping # clinic follow up Carpo-metacarpal dislocation Refer to orthopaedics FRACTURES Carpo-metacarpal fracture dislocation Bennet’s 1st CMC joint Intra-articular fracture of base of 1st MC Refer to orthopaedics 2nd to 5th Refer to orthopaedics Metacarpal Fractures Assess rotation in flexion If any rotation then refer to orthopaedics First Uncomplicated/non-Bennet's Scaphoid type cast Fracture clinic Second to Fourth Volar slab

Fracture clinic Fifth Shaft undisplaced volar slab & fracture clinic follow up Displaced Refer to orthopaedics Neck assess for rotation of little finger If no rotational deformity. Buddy strap/padded crepe and discharge with advice leaflet (RAH), at IRH refer to # clinic

If rotational deformity or angulation > 30 o then refer to orthopaedics. Phalangeal Fractures Assess stability by clinical examination Assess rotation in flexion Angulated or rotated unstable fractures refer to orthopaedics Displaced condylar, neck or basal fractures Refer to orthopaedics Minor Phalangeal fractures buddy strap & review in # clinic Major Injuries Refer to orthopaedics

PELVIS The pelvis is a ring structure so indirect violence will disrupt the pelvis in two places

Anatomy Pelvic ring stability is provided by the ligaments shown below:

Fractures of the Pelvic Ring Tiles Classification (Tile,M: Pelvic ring fractures. Should they be fixed? J. Bone and joint surgery. 70B: 1-12 1988) Type A Stable A1-Fractures of the pelvis not involving the ring. A2-Stable, minimally displaced fractures of the ring. Type B Rotationally unstable, vertically stable. Open book/lateral compression B1-Open book B2-Lateral compression: ipsilateral B3-Lateral compression: contralateral(bucket handle) Type C Rotationally unstable, vertically unstable, ipsilateral SI joint and rami C1-Rotationally and vertically unstable C2-Bilateral C3-Associated with acetabular fracture. Young & Burgess Classification (J.Trauma 30:848-56.1990)

Stability can be judged by fracture pattern, direction of force of the injury and by knowledge of the pelvic ligamentous anatomy. See overleaf. Young and Burgess Classification

Type Description Mechanism Un/Stable Picture Lateral Compression

Unilateral pubic rami fractures, with or without symphysis injury, and bilateral rami fractures with or without pubic symphysis injury

LC1 Unilateral ramii (Transverse) & ipsilateral sacral compression

Lateral force compressing sacrum

Usually stable

LC2 Unilateral ramii & ipsilateral post. Iliac#

Lateral force compressiong ilium

Usually stable

LC3 LC I&II &

contralateral APC

Trapped between unyielding object/rollover

Unstable

AP Compression APC

Direct Anterior Force

AP1 Symphysis <2cm or ramii (vertical) & ant.SI ligament stretched

Low to moderate energy forces (sports)

Stable

AP2 Symphysis >2cm or ramii & ant SI ligt torn (+ the ligaments of the floor of the pelvis)

High energy- ‘open book’

Unstable

AP3 Symphysis or ramii & ant & post SI ligament torn

High energy-pelvis rotates externally until the post iliac wing contacts the posterior sacrum

Very unstable

Vertical Shear (VS)

Ant & post vertical displacement

Fall from a height with vertical forces

Unstable

Combined Mechanical

(CM)

Combination of other injuries

combination Unstable

Please note that ‘springing the pelvis’ is not a reliable sign of pelvic fracture, except where there is gross disruption of the pelvic ring (where it is, therefore, unnecessary) Massive blood loss can occur with pelvic fractures Pelvic binder should be applied (if not already done so prehospital) to all suspected significant pelvic #s Refer all pelvic fractures to orthopaedics. Only exception to this is undisplaced pubic rami fractures. If patient able to mobilise and has adequate home support then discharge with analgesia/advice. Obviously, an elderly patient must never be sent home from the Emergency department when unable to weight bear, irrespective of apparently ‘normal’ x-rays. He/she should be referred to the on call orthopaedic on-call for admission. Not infrequently, further x-ray studies reveal pathology not seen on the initial films

ACETABULUM Refer to orthopaedics

HIP

Dislocation of hip Leg held shortened and internally rotated Examine for sciatic nerve integrity Refer to orthopaedics Generally reduced under general anaesthetic Fractures Femoral Head Fractures Refer to orthopaedics Femoral Neck Fractures Classification Intracapsular Subcapital Transcervical Extracapsular Basal Intertrochanteric Subtrochanteric There is a system of fast tracking fractured neck of femur patients at RAH 1. Diagnosis suggested by history of fall, leg lying shortened and externally rotated 2. Ensure adequate history and examination 3. If suspected, obtain IV access and provide analgesia, intravenous morphine.

Remember patient has to get moved for x-ray 4. When putting in venflon take off bloods including group and save 5. Identify patient to nurses as? NOF. Send to x-ray. 6. Once returned from x-ray- if diagnosed as #NOF then inform nursing staff and they

will contact orthopaedic page holder to arrange a bed in orthopaedic unit. 7. If time permits and history suggests collapse then organise ECG in department,

otherwise this can be done in the ward. 8. Refer patient to orthopaedics, giving the ward that patient is going to. 9. Orthopaedic on-call will review patient in ward, not in ED Classification of hip fractures:

Garden’s Classification of neck of femur fractures

NB: 1. A flexion contracture of the hip may result from psoas spasm secondary to

pelvic pathology e.g. appendicitis etc.

2. Other causes of hip joint pain include: Reiter’s Syndrome Rheumatoid Arthritis Ankylosing Spondylitis Bony Metastases (thyroid, kidney, lung, breast, prostate)

Femoral Shaft Fractures Manage patient in resus/ensure senior staff involved Patients can lose 1-2 litres of blood around fracture Resus as per A, B, C IV access, fluids, analgesia, Femoral nerve block with 0.5% bupivocaine ( Marcain) is helpful in pain control. If no pelvis fracture, place in Thomas splint. The ED/Fracture clinic nurses will assist you in applying this. Refer to orthopaedics

KNEE

Soft Tissue Injury Careful history and assessment 1. Unstable Refer to orthopaedics 2. Locked knee Refer to orthopaedics

3. Tense effusion Refer to orthopaedics 4. Small effusion Padded crepe & crutches. Review in ED ST clinic at 2 weeks

Dislocated Patella Usually dislocates laterally Reduce by extension of knee. Use entonox For first dislocation place in pipestem cast For recurrent dislocation- padded crepe crutches. Ortho fracture clinic follow up. Fractures Distal Femur Refer to orthopaedics Patella Refer to orthopaedics Tibial plateau Refer to orthopaedics Tibial Fractures All tibial shaft fractures should be referred to orthopaedics Fibular Neck Fractures Assess knee stability Check ankle Check function of common peroneal nerve- dorsiflexion, eversion of ankle.

Sensation lateral border of foot If any of above impaired- refer to orthopaedics

Fibular Shaft Fracture Padded crepe and ortho fracture clinic follow up

ANKLE Soft Tissue Injury Obtain history Document if patient can weight bear Examine and document tenderness at fibular neck, Achilles, Os Calcus, malleoli, 5th MT

Use Ottawa ankle injury rules to determine need for x-ray. If in doubt err on side of caution. If no fracture then treat with RICE R rest for 24-72 hours I ice 10 minutes every 1-2 hours for first 2 days. No direct skin contact C compression. Tubigrip or padded crepe E elevation. Ankle needs to be higher than knee Ensure adequate analgesia Advise that will settle but can take 8-12 weeks to heal If unable to weight bear then provide crutches and review in ED soft tissue clinic in 2 weeks Ruptured tendo-achilles Simmond’s calf squeeze test. Document whether palpable gap present. Refer to orthopaedics to allow discussion re operative vs conservative Rx Fractures Distal Tibia Including medial malleolus. Refer to orthopaedics Ankle Classification Weber Type A Fibula # below syndesmosis Type B Fibula # above syndesmosis +/- medial injury Type C High fibula # + medial injury-diastasis of tibia and fibula X-ray careful assessment of talus within ankle mortice Clinical record medial joint findings bruising/swelling/pain

Management Type A BKPOP or BREG boot, # clinic follow up Type B No Talar shift BKPOP #clinic follow up Talar shift Refer to orthopaedics Type C Refer to orthopaedics Bimalleolar fractures Refer to orthopaedics Isolated medial malleolus fracture Unless small avulsion. Refer to orthopaedics All ankle fractures, unless very small avulsion fractures from the tips of the malleoli, should be followed up at orthopaedic fracture clinic. Minor avulsions treat symptomatically & discharge with advice leaflet (RAH)

FOOT Fractures Talus Refer to orthopaedics Os Calcus Ask for specific calcaneal view

Measure bohler's angle. Normally about 40 0 Refer to orthopaedics

Metatarsals 5th Metatarsal Base Note in children that the epiphysis is vertical and fractures are transverse Treat in padded crepe/crutches Discharge with advice leaflet (RAH)

Beware Jones fracture - fracture distal to intertarsal joint. This must be immobilized in a Breg boot or POP Shaft of Metatarsal BKPOP. Ortho fracture clinic Multiple fractures Refer to orthopaedics Fracture Dislocation Refer to orthopaedics True lateral x-ray of foot for all swollen feet or if run over Phalanges Great toe Treat with Toe spika. Plaster slipper if in great pain 2nd-5th toes we generally do not x-ray these unless dislocation suspected. Treat with buddy strapping. PAEDIATRIC FRACTURES There are some types of fractures, which are unique to children 1. Greenstick fracture break in one cortex only 2. Torus fracture bend in bone without cortical breech 3. Plastic bowing fracture 4. Salter & Harris epiphyseal fracture. Type I-V Undisplaced/greenstick # distal radius or ulna Treat in colles POP Undisplaced torus fracture: RAH: place in splint and discharge with advice leaflet

At IRH these injuries are still followed up in # clinic Displaced Supracondylar Assess distal CSM Refer to orthopaedics Undisplaced Supracondylar Above elbow backslab Ortho fracture clinic follow up Clavicle Ensure assess and document distal CSM Undisplaced Broad arm sling discharge with advice leaflet (RAH) Displaced Broad arm sling ortho fracture clinic Lateral Malleolus BKPOP ortho fracture clinic follow up Tibia Discuss with orthopaedics May require admission for elevation to reduce risk of compartment syndrome Metatarsal BKPOP ortho fracture clinic follow up Non Accidental Injury X-ray signs Certain x-ray findings are highly suggestive of physical abuse. These include rib and skull fractures. Other x-ray features, which may indicate abuse, include: 1. Multiple fractures in different stages of healing 2. Multiple metaphyseal/epiphyseal injuries 3. A single fracture with multiple bruises. 4. Subperiosteal new bone formation. Occurs after few days of trauma. If present on day

of “injury” it can be concluded that some time has elapsed between injury and presentation.

5. Corner fracture. Small fracture at the corner of metaphysis of long bones

Iain Young October 16